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.
For the past few days at a brand new elective site, I have had to do my investigative work the old-fashioned way as the service desk tried to sort out my computer and dictation credentials. A series of missteps had left me without any access to up-to-date investigations or previous consults.
If anything, it was an opportunity for me to be more conscientious about what information I needed, more creative in procuring the information, and more inquisitive about the critical points.
However, now that my access has been restored and my methods rejoin the 21st century, the question becomes: will I lose that keener eye at the bedside and at the desk with the patient chart?
After two days of clinical exams, I would summarize my performance in one word: “questionable.”
A week’s worth of practice and review did not fully prepare me for the scenarios I encountered. With my every word and motion, I hesitated, I fumbled, and I missed. My embarrassment was only compounded by the realization that after each self-contained ten-minute moment of sheer terror, I had another scenario waiting, only to repeat my performance again.
It was a bust.
Since starting this rotation, I have participated in code blues - emergency resuscitative events in the context of cardiac or respiratory arrest - on a regular basis. There are many reasons for the patients we see to arrest, from their inherent risk factors, to heart-related illnesses that have brought them into our care.
In that sense, we are always weary of our sickest patients. The monitors scan intently for troubling rhythms, the nurses routinely watch the patients, and the crash cart is always ten seconds away. “He might code tonight,” you can often hear them warn as the handover occurs for the resident on overnight. It is spoken in anticipation, it is spoke for preparation.
But I wonder where along that blurred line does anticipation end and expectation begin? If we expect something to happen, does it change how we react to that situation, that it was meant to be? If we can see the warning signs ahead, could it be something that can be avoided?
Some diseases naturally run their set course regardless of what we do; others can be altered. What we do along the way, including codes, depends on an understanding and agreement between the patient and the health care provider. I hope that as I continue on in this field, that the anticipation of one’s outcomes does not prevent me from asking the question, “what more could I do to help you?”