My rotation through Internal Medicine started off with a month-long stint in the Intensive Care Unit (ICU). Names were often misleading in the hospital regarding what types of patients you were going to encounter; I would see patients strolling into the Emergency Room for the common cold and another patient with trauma and major parts of his hand missing to the “low-key” walk-in outpatient clinic. However, the ICU was perhaps the most aptly titled unit I had rotated through, and the experience was intense in more ways than one. Where I was often used to seeing ten different patients with one acute problem elsewhere, I now saw one patient with ten chronic problems here. Looking back now, the entire month was one big blur where days bled into one another, quick rounds turned into endurance-testing marathons, and one dysfunctional organ system precipitated the downfall of another, like dominoes.
The ICU renders itself as a gateway for the acutely and chronically weak, patient’s whose lives are literally placed in the mercy of a higher power: what that power is depends on who you ask. I would be lying however, if I didn’t admit that the ICU has a distinct aura of holiness. Family members often tiptoe and whisper in profound deference to the medical team and to the patients as if the patency of the patients’ airways depends directly on their ability to minimize all sound. All who enter seek antidotes for their crisis, a distress composed of both physical and emotional elements and sometimes, the emotional masquerading as physical. Replace the pews with endless stretchers, the stronghold confessional with a curtain-veiled bed, and a priest cloaked in black bearing a cross with a physician shrouded in white bearing a stethoscope. Trade religious fervor for actual fevers, church bells for code calls. Some find God in a stained glass, we see god in a CBC. What we lack in offering salvation and moral and spiritual guidance, we make reparations for by providing physical and mental relief often in the form of pharmacological deliverance.
However, just as prayers are often not enough, so are the limitations of science. What do you do when your knowledge is failing, your faith wavering? When you’re forced to make a home out of a barricade?
For the greater part of my temporary stay in the ICU, we had a 66 year-old female patient with recurrent AML and breast cancer. Her immune system was completely dysfunctional and as a result contracted viral pneumonia which progressed to acute respiratory failure, marking her membership into the medical ICU. Over time her health was quickly deteriorating while her devoted husband, David, as we’ll call him, watched on. David would hobble in with his cane every morning with a new balloon expressing the universal “Get Better!” or “Wishing a quick recovery!” only to sit helplessly while his wife remained intubated and isolated.
Interacting with and observing David, I learned firsthand that grief dons many guises: denial, anger, bargaining, depression, and acceptance. And while most people go through the five stages of grief once their loved ones have died, David was living through the process while his wife was still breathing, in that hazy medium between being alive yet not fully awake or alert.
During the hours of 8-10 in the mornings, patient’s family members are restricted from entering or visiting the ICU so to maintain patient confidentiality while the medical team rounds. While patient confidentiality is important, I always thought the real reason was so the medical team could be candid and often, brutally honest, concerning the discourse of their patients. One of the attendings, however, encouraged participation of family members during these hours so to minimize all barriers between the professionals that manage the patient’s health and the individuals that know the patients far more intimately. David was the only member that did not want to actively participate in the conversation concerning his wife.
David thought there were too many negatives in the day-to-day dealings with his wife’s healthcare in part due to her deteriorating labs and imaging. He would much rather stay in the positive, and that meant focusing solely on the end point: curing his wife. The fact that cancer has no cure was simply a matter of opinion. This was perhaps the most potent marker of David’s denial. Denial soon transmuted into fiery anger where oncologists and other personnel were barred from speaking to his wife if there was any suggestion that his wife’s options may be exhausted. Soon crept in bargaining where David sought to regain control in a period of immense vulnerability. Every sentence seemed to start with “If we could…” If we could just try to get her breathing on her own, she could be strong enough to get the therapy for her AML. If we could just allay his wife’s anxieties, she would breathe better. If we could just not mention to his wife the magnitude of her condition, she would heal faster.
It wasn’t long before depression succeeded bargaining. David’s optimism was withering away, and with it went his daily balloons. David himself, became more infrequently seen in the ICU until one day his sadness was overthrown by acceptance as he realized that his wife was simply no longer his wife, but a mere shell of who she once was despite all ventilatory and rescue efforts. David paid his farewell. A few days after, his wife was taken off ventilatory support with a priest by her side while David was at home, unable to bear the loss in person.
At the end of life, Buddhists have their mantras, Hindus their sutras, and Catholics their Last Rites. The Jews follow their Jewish law and Muslims the Sharia law. Outside of religion, David had a well-circumscribed process to define the enormity of what he was going through. This not only comforts the dying but soothes those that are left in the wake of death. However, the process physicians undergo in the aftermath of patient death seem to be rather unwritten and unspoken. What do physicians rely on to cope or better yet to learn what their respective roles are in confronting mortality? How do we learn to steer clear from two competing polarities of appearing either too lachrymose or even worse, too callous?
We learn to get acquainted with the chaos of code calls, the sheer carnage that accompanies trauma, and the task of dissecting the dead, but how does one reconcile oneself with the active process of dying? Dealing with family members of another patient who was in her 90s with baseline dementia and had recently suffered a stroke, I accompanied the APN of the ICU to discuss the patient’s options regarding what the family and the patient would want in the event that she codes. Two months shy of retiring after decades of working in similar settings, the APN shared that it never gets easier having to start or end that conversation. However, the APN further stressed that, while there is never a single right answer, asking the question marks the primary step in assessing what gaps need to be addressed regarding patient education when it comes to administering possible end-of-life care and the emotional burden that may or may not accompany such decisions.
Consequently, if all this attention is being paid towards patient education in processing patient mortality, where is the spotlight in the medical education system for physicians-in-training? Efforts have been made to understand the methodology of grief from David’s and the stroke victim’s family, but what about the caregiver’s? How are we to dissect it, to confront it, to understand the process better if the process isn’t identified? Even if there was a greater framework in helping physicians address patient death, should it ever be easier to accept a patient dying on your service? Does the end result of making the process “easier” not become morbid itself?
My four weeks in the ICU have been some of the most rewarding but also some of the most depressing. It’s ironic that the patients who are sedated, intubated, and isolated, who seem to be neither in the realm of life or death, are the ones who teach you the most about living and about dying. Since then, I’ve seen many patients pass on in many different settings. The shock value ultimately gets blunted, but never the event itself. I’ve also seen a variety of coping mechanisms from caregivers: some externalize, some become immune, some use humor to lessen the blow of losing a patient, but in the end, it pummels us all the same.
When it comes to death, I’ve only really learned that the narrative of medicine is keen to focus on patient life, and not enough on patient death unless it is solely preventive. That’s not to insinuate that a conversation isn’t taking place, just not one with any active verbs. It’s unfortunate especially because when a patient dies, he or she leaves more than just their family behind, but an entire healthcare team that may not always have the tools to grapple with the repercussions. When a patient falls victim to a disease, we all become victims, in our own ways, succumbing to a voiceless loss, one that deserves better characterization.