Most medical schools address caring for a dying patient early on, since it is a distressing subject for most young physicians. As a first-year radiation oncology resident I have cared for many patients at the end of their lives. Thus far the clinical care of these patients has usually been straight forward, but knowing how to handle their death is an entirely different issue. Most young physicians are unsure of how to approach the death of patient with the patient's family and how to handle their own emotions. We do not always receive the best advice from other physicians we look to as mentors.
Last month on the hematology/oncology service, I had a particularly young patient who had been in the hospital for 2 months prior to my assuming his care. He had a very rare, highly aggressive tumor that was not responding well to the chemo/radiation therapy. Pain control was a persistent issue for this young man, and his family was told early on that his prognosis was poor. The palliative care team was called to follow the progress of the patient. The patient and his family activated DNR orders.
When I began to care for this patient, I was initially overwhelmed. I spent many nights reading through his 3-volume medical chart in order to get a handle on all his previous treatments. My patient was discussed in great detail during morning rounds each day. He was completing his second round of chemotherapy and his acute side effects were severe. I had many conversations with the patient and his family about their treatment goals. I made it my goal to see some improvement in this young man while I was caring for him. Soon after the completion of this second round of chemotherapy we did begin to see some improvement. I began to hope.
His condition improved to the point where his tracheotomy tube could be capped allowing him to communicate better. He was able to get out of bed and undergo physical therapy. I was quite pleased with his progress and began to think that he could return home with his family. This upturn lasted only a matter of days, however, and his condition deteriorated. After seeing the possibility of improvement in this dying patient, I was frustrated. I was attached to him and viewed improving his condition as a personal goal. It was emotionally difficult to watch this patient die, and, at the same time, explain to his family that he was dying.
Many physicians respond to a situation like this by immediately assuring themselves they did everything they could for their patient. These physicians begin conversations with colleagues or family by saying, "We did everything we could but…." I have never understood this type of justification. It seems to me that physicians who approach their patient's death in this manner are simply trying to distance themselves from the death. In saying, "We did everything we could," physicians are talking about themselves, about what "they" did, that they are blameless. They are not attending to what has happened to the patient and his or her family.
Patients expect and seek comfort in the fact that their physician will take responsibility for their care. Whether you are seeing patients for routine exams or caring for them in their dying days, you should be their advocate. I think the best piece of advice I have received thus far in my residency is to always take responsibility for your patient. It may seem like a simple piece of advice, but, when you are treating dying patients, taking responsibility can be difficult. It becomes so easy to pass by a dying patient's room and concentrate all of your efforts on those patients who need acute care. It becomes easy to seek solace in the fact that you "did everything you could do" for the patient. I am reminded daily by my medical team that doing everything you can do is part of your job, and it continues even when "all you can do" is to give care to a patient who is dying.