One of my clinical preceptors always reminded students: “you are allowed to make all sorts of mistakes; but whatever you do, do not kill the patient.” A patient dying while under our care is something everyone fears. How did it happen? Why did it happen? Was it unexpected? What role did we play in it? What could we do about it? It is a major topic of our healthcare system, and the reason clinical teams run morbidity and mortality rounds. After all, if a therapeutic visit ends in death, it warrants a second look. Did we do everything right? Or did we fail?
Now that I am on a palliative rotation however, the metrics of care have changed. There is an understanding that the patients we see are at the final stages of their illness. Our role in this context is no longer to treat, but to make patients comfortable as we allow the conditions to take their course. Our new metric is suffering.
The transition has not been without its difficulties. It is hard to resist the urge to act, to auscultate, to palpate, and to investigate after so many months on the other side of the fence. No longer is death the undesirable outcome, but rather the inevitable conclusion of everyone I see.
In the short time I have been in this rotation, I have already had the privilege to be involved in the concluding days of a number of patients who have since died of their disease burden.
It is a strange and humbling realization that within the coming year, the mortality rate of all the patients I have seen in this rotation will be or close to 100%. And for this service and for everyone involved, that is all right.
Being able to create a great Curriculum Vitae (CV) is an important long-term skill to have. Latin for “course of life,” it is a document that serves to represent you ahead of any formal face-to-face interaction, to tell the story of who you are and what skills and experiences you bring. Thus, making a great first impression on paper is very important.
"Unhook me from these machines. I am going home now and not a moment later."
More than an hour before, I stood by the bedside and watched as the team worked furiously to resuscitate him. Esophageal varices, a cluster of severely dilated and pressurized veins, had been slowly brewing within him over his many years of alcoholism. With the tension of its walls reaching the breaking point, the time bomb had exploded in a torrential gush of blood.
It has taken almost an entire year to get to this point: I am feeling skilled enough to tackle some of the more complicated patients on my own; I am feeling confident in my work; I have developed strong working relationships with the nurses and staff.
And yet, despite all of the blood and sweat I had poured into this year to make it to this point, I suddenly found myself having trouble leaving it.
It took me by surprise, on a quiet morning in the psychiatry ward. I had arrived a little earlier from my internal rounds to return some books lent to our group by a preceptor. Expecting him to be arriving later, I had originally intended to leave his books in his mailbox. Instead to my surprise, he had unexpectedly arrived early to check on a few issues.
"Tom? What are you doing here so early? Are you back on Psychiatry?"
"Actually, I came by to return your books." His brow perked up. We usually passed along his books to the next person rotating through psychiatry. This was unexpected.
"Were you the last one through Psychiatry?"
"I believe so." He sank back into his chair as a look of sadness filled his face.
"I see…What will you do? Do you know?"
"I don’t know yet. Things are still up in the air. A lot can change."
"Well…Pass this along to your friends as well. No matter what happens from here, I wish you guys all the best in your training and hope you guys find something you enjoy doing. It was a pleasure to…" As he continued, sitting there cleaning his glasses, shyly looking away, I realized that he was actually bidding me farewell.
I suddenly found myself welling up with emotion. I realized then it was possibly the last time I ever worked with him or saw him. I realized then just how close we were to the end of third year. I realized how many people have contributed to my experience this year in hospital and how much I would miss them.
"…It was a pleasure. Good luck on everything. We will see you tomorrow?" He stood up to shake my hand with a smile. For a moment, we exchanged an understanding look to each other, imagining that we were on a typical day at work, expecting to see one another tomorrow morning for rounds.
"Yes…See you tomorrow."