Impotent:
how you feel when a patient under your care is dying, and medical science has nothing more to offer. When you’ve tried everything, and nothing has worked.
You
feel like a failure—so “not God” as is sometimes still expected of physicians.
It haunts you, especially when the patient is a child, or someone you know, or
your own parent.
My
father, for example, died a perfectly modern medical death, and there was
nothing I could do about it. Post-operative complications of failed vascular
surgery compounded by chronic lung disease took him down even though he was
surrounded by life support paraphernalia of every description. Even though he
was attended 24/7 by bright, dedicated doctors and nurses throughout the entire
ordeal.
In
the end, he died alone in the Intensive Care Unit because people were too busy
to notice when he took his last breath. If the alarms hadn’t called them to
attention, no one would have known. He died alone while I frittered the moment
away with my mother in the visitors’ lounge down the hall where we’d gone for a
cup of coffee. No one came to get us. No one drew us to his bedside in time to
say one last good-bye. And by the time we were summoned, it was too late.
The truth is that
doctors come to expect this kind of thing. Family members do not. Right from
the start medical students are warned about it, and then they are trained to
deal with it. For me, the seeds of indoctrination were sown on the very first
day of medical school when the dean of the College of Medicine stepped up to
the podium, and one hundred eager students, terraced like rice paddies on a
hillside, snapped to attention.
He
congratulated us on our academic achievement and our noble aspirations. He
spoke about tradition and honor. He went on and on about dedication,
self-sacrifice, excellence, courage, and the ethics of exhausting work. But the
bottom line was, “Do no harm.” And in the next breath he declared in no uncertain
terms, “The day will come when a patient under your care will suffer or die
because of something you did, or something you failed to do, and it will be
your fault. You will have no one to blame but yourself for having been careless
or hurried or ignorant or, God forbid, arrogant or indifferent. You will bear
the burden of guilt for the rest of your life. You will never get over it.”
He
surveyed the blank expressions arrayed in front of him, and then he went on.
“If for a moment you doubt what I am saying, you are invited right here and now
to gather up your belongings and leave. Go. Depart.”
He
paused, stepped away from the microphone, and waited. He scanned our fresh
young faces row by row as if he knew exactly who among us would be unable to
bear it when—not if, but when—a patient died under our care. I remember locking
eyes with the man as if he were able to judge strength of character and depth
of devotion by the size of one’s pupils. He was waiting for the fainthearted
among us stand up so everyone could get a good look at what it meant to be a
coward. He might just as well have asked those of us who had dropped acid over the
weekend or those of us who preferred unprotected sex to stand up in front of
everyone so we could hang our heads in shame as we shuffled out the door. But
no one left. A few of us shifted nervously in our seats, but who would admit
it?
When he stepped back up to the microphone he sounded incredulous. “No one?”
He paused. “Then God help you.” And with that he doffed his glasses, picked up
his notes, and left.
One hundred
fledgling medical students responded with stunned silence. Then someone in the
back row chuckled, as if to say, “What the hell was that?”
That, we would
learn, was the power of prophecy. It was inevitable that patients—even children
who were critically ill or injured—would die under our care, in the emergency
room or on the operating table or in the intensive care unit. Despite our best
efforts, patients would slip away from us. We were warned to expect it, and we
were taught how to deal with it.
In medical school,
when a patient died, we learned to tell ourselves there was nothing we could
have done to prevent it. We were not to blame. It was the incubus of
exhaustion, the sophistry of the gods at work. Put it out of your mind, we were
told. Better yet, pretend it never happened. We were told to move on. We had work
to do. Hope to instill. Trust to inspire. Destiny to ordain.
For four years the
men of medicine took hammer and chisel to us until compassion fell away like
dross—a smoldering pile of words that longed to be spoken, of hands that begged
to be held, of tears that never fell. And out of it we emerged
transfigured—tireless, dispassionate, infallible. Or so we were led to believe.
Over the years,
though, experience taught me otherwise. When I knew a patient was dying, I learned to stay
at the bedside. To check for a pulse myself. To place my stethoscope on the
patient’s chest and listen for a heartbeat even though the monitors had already
gone silent. I met with the patient’s family and explained what had happened. I
did my best to answer their questions.
"We touch heaven
when we lay our hand
on a human body."
~Novalis~
I didn’t make up
excuses. I didn’t turn the situation over to the nurses, or the hospital
chaplain, or to someone from social services. I finished the job.
I believed in the healing power of the physician’s presence and
the importance of his touch, and I still do. We all did. We respected the roles of ritual and expectation in
healing, and we honored the importance of compassion and human connection in
patient care. Of course, this was in the day before the exaltation of the
ten-minute office visit. Back when we still made eye contact with patients. When
we enjoyed a holistic relationship with them, a trusting kinship that helped them
heal. Even when healing was beyond our grasp, we stayed with our patients to
provide support, comfort, and hope.
Today’s
overwhelmed health care provider may suggest this is what we have nurses, social
workers, psychologists, pastors, and family and friends for. But by disengaging
himself from the patient's psychological, emotional, and spiritual life, the
physician sacrifices his connection with his patient, and with it, he
surrenders his calling. His passion. His sacred duty.
Looking back, I realize
that to deny the truth is to ignore a festering wound, a
disfiguring
blemish on the snow-white complexion of the soul. You can slap a bandage over
it so it doesn’t show, but still, you know it’s there. The truth is that guilt
aches and throbs even out of sight. It is as contagious as fear, as pernicious
as anger, as deadly as pride. And it never heals.
I was twenty-three-years old when I started medical school. I practiced Family Medicine for over thirty years. It took me that long to acknowledge the truth. You can put fear and doubt behind you. You can move on to other things, but when a doctor attends a patient's death, he bears the loss forever in his heart.
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