Dr Janine Winters
When I started my career shift from Hospital Medicine to Palliative Medicine in 2004, my mother asked me “Why in the world do you want to work with people who are going to die? That is so depressing.” My answer then and my answer now is the same. “I am a doctor, I already work with people who are dying—and I know it can be done better.”
As an American medical student, I witnessed a clinical situation that I had never before considered. I was as fresh as fresh could be—it was the summer holidays of 1991 and I had completed only one year of medical school, all classroom based. I was participating in a summer programme and spent three weeks working alongside the Family Medicine residents on their hospital rounds and on evening call. I wrote about my experience at the time, in an essay I called “Dying in a hospital”. Recently I found it again, my student-self speaking to me across a 25-year abyss.
I wonder why this interaction affected me so deeply. I wonder why most of my classmates colleagues did not question the “rightness” or “wrongness” of what we first observe in clinical medicine. What was it in me that I not only observed clinical medicine, but I saw? I saw that doctors deal with birth and death and both have their place. I saw that sometimes in medicine, we do things TO people rather than FOR people. I saw that, at their most vulnerable, people depend on their doctors to protect them as well as try to heal them. I saw that the outcome is not the only thing that is important—the journey is important too.
Now, as a mid-career doctor, I teach medical students. I often tell them to pay attention to their inner voice as they observe clinical decision-making. If it doesn’t seem “right” on a moral level, this is probably correct. Their inexperience makes them more sensitive to seeing morality and emotion. Years in health care can desensitise providers, who become used to doing things because “that is the way it is done”. They no longer see. They no longer ask “why”. It is difficult to ask “why” year after year. The observational acuity of medical students is that of the boy who can see the emperor has no clothes.
The story starts in the resident’s lounge, where I am waiting to follow a doctor and observe some clinical medicine…
Dying in a Hospital
I wait with my feet up in a reclining chair. Now and then an overhead page startles me back into consciousness. She comes into the room abruptly, blond-brown streaks of hair flying behind her. I lazily open my eyes, pausing to put on my glasses before drawing her attention to my corner of the room.
“Hi” I say.
“Hi, I didn’t notice you over there,” she replies.
I introduce myself. Second year medical student. Rotation. Learning. Morning free. Do you have anything for me to see?
“Sure,” she replies. “I have to go downstairs now to help my patient die.”
“Oh,” I say as I follow her to the elevator.
She is frank and open. She is a third year resident who has cared for this patient for three years. Now the situation is hopeless.
“She was such a nice lady. I know her whole family. Her son-in-law also came to see me at the clinic. But it’s hopeless now. She was a fighter, she’s been in the hospital for six weeks. We don’t know what it is, but it’s messing up her lungs. Remind me to show you her x-rays.”
We arrived in the ICU, me a line towed behind. I struggle into the nurses station and awkwardly wait for a seat. We find her chart. It tells her story.
Dying in a hospital happens in steps. At first she is just sick. In a bed. Countless tests. Monitor her fluids, her sodium, potassium, saturations, sugars. Listen to her lungs, her bowels, her heart. Biopsy, sample, draw, test, evaluate, consult. Antibiotics. Nothing is working.
The second step of dying in a hospital is being sent to the ICU.
Tubes, gold-fish-bowl windows, beeps, voices never end.
Please, no tubes.
Please, no ventilator.
Let me die when God wishes to take me.
The third step is intervention. Just this tube. How about a ventilator for a while so we can figure out if we have another antibiotic to try. But to no avail.
The fourth step is what happened yesterday. A discussion with the family is documented. This person, our patient, their mother is now a “no code”. What a funny term. It is the only way they let you die in a hospital.
Today we embark on the final step. The old gal won’t code, so we must stop the machines keeping her in this state between life and death.
I see the x-ray. Only a tiny triangle of lung is left.
We consult one last time. Then we write the order. Wean her. Turn the ventilator to one half.
We go to see her. She opens her eyes.
“Do you want to be on this ventilator?”
She shakes her head, no.
“We are weaning you off of it since we know you don’t want it.” A pause.
“I have a feeling you will see God this afternoon, Mrs. B. Tell him we said hi.”
As her family walks in, my new mentor breaks down and cries. A doctor who still can cry for her patient. She cries with the family. My own eyes mist.
We hang around. We can’t seem to leave. The family will stand vigil, but we must see other patients. But we linger on.
Finally, a beeper breaks in. We have to move on. Be back in an hour.
An hour later we are on the other end of the cycle. An infant is squalling.
Possible meningitis. I hold him down for the lumbar puncture.
Mom, with crooked lipstick, is worried. Dad paces.
“Is this your first?”
We find a phone.
“Mrs. B is OK?”
“Decrease her vent… this is so hard to say… decrease her vent to zero.”
She will still “trigger” the vent on her own for a while. But we know it won’t last.
Forty-five minutes later she is dead. I’ll never see the family again. The doc who cared is on pediatrics when it happened.
An autopsy will be performed. Then all the consultants will know why she died. But I know she died a death of sequestration and prolongation. She died the death of a woman in the hospital.
Janine Penfield Winters, M.D.: Janine is a palliative care doctor at Otago Community Hospice and teaches in the Bioethics Department, University of Otago, Dunedin.
Acknowledgement: Thanks to St. Vincent Family Medicine Residency, Erie, PA.