Physicians often shy away from preparing their patients to die

AT THE START of medical school, we met our first patient during our human anatomy course.

We were curious and excited to study what happened to this person during their life. We hypothesized as to their cause of death—and at some point, we confirmed that hypothesis. The visual of our first patient stays with us even as we start to rationalize that person as parts that we need to study. But someone died and donated themselves to lay in this space and teach us about something more important than body parts.

That first patient is a reminder that we are charged to both save lives and prepare our patients for dying. But for the rest of our career, we adopt the perception that we can preserve life, even though our first image of medicine is death. Somehow, many of us become shy to that reality.

The burden of this conversation is on us, and it always has always been.

The beauty in death is the reflections that occur in the weeks, days and minutes prior to it, which together make up a summary of someone’s life. Why then do physicians view this time-honored decline as a series of clustered medical problems, when it really is just someone moving toward death? Are we so concerned about treating just one more condition, and do we actually think it will solve the growing list of medical problems that dying patients have?

Every death is memorable
I have attended many deaths: slow deaths, sudden deaths, expected deaths and unexpected deaths. Every one is memorable in its own way.

Recently, I cared for Alice (fake name) who had end-stage renal disease and was on dialysis. She was having trouble getting through those sessions due to her low blood pressure. She wanted to keep fighting until the end, but she’d already decided not to be resuscitated.

Eddie, her husband (also a fake name), told me he was waiting for the call that she had died. He didn’t want to see her suffer and, while he wanted to give the decision a few days, he was ready to talk about hospice.

I decided to sit with them both and ask about their lives. They met through friends, and he remembers seeing her through a doorway. He liked to go fishing, which she didn’t—but she would read a book while they were together in the boat. Now here we were, Alice in the bed with her eyes closed. I touched her shoulder lightly to include her in the conversation about their past, but she only moved her eyes a little.

That day, as on many days prior, I compared dying to pregnancy to “soften” the description of this decline. Here’s how I see that comparison:

The way we come into this world is often the way we go out. Pregnancy is a slow process that ends in the separation of mom and baby. In dying, the same steps occur as someone we love separates from us. With the exception of sudden deaths, there is a slow, predictable decline that can and should be recognized.

After our talk, Eddie headed home. A few hours later, I was called to Alice’s room for an emergency. Her telemetry was on as I watched her ST segments shoot up and her heart rate go from 120 to 60 to 20 in minutes. She stopped breathing, we checked everything we could and ensured her comfort.

When I got Eddie on the phone, I told him that this was the call and that he should come back. After he arrived, he and I sat for a few minutes at her bedside, her in the bed and him on the couch. This time she was alone with her book, and Eddie was on the shore.

They got that moment of reflection together, and I’d like to think that Alice saw her path when we talked in the room about the boat. Most importantly, I had spent just the right amount of time that morning to sit and talk.

Even with years of hospital and hospice experience, I didn’t think Alice would die that day, and I’m not sure why that talk occurred. Something in me recognized that it needed to happen.

A good death
My advice: Don’t take these moments away from yourself or your patients. As physicians, we all give many gifts of life, but we have only one chance to help give someone a good death.

We all need to cozy up to death the same way we scrambled around the anatomy table learning about our first patient. This gives us an endless supply of empathy and keeps us humble every day in the face of all the things we do not know.

But the burden of this conversation is on us, and it always has always been. It is not fair to wait for patients or families to bring it up; when we don’t acknowledge that death is near, they feel like they are giving up. Instead, we need to remember to find beauty in death and to be thankful for that first patient. That was when we began to learn how to take care of life.

Colleen Poggenburg MD, MS, is a lifelong resident of Wisconsin who received her medical degree from the Medical College of Wisconsin and is board certified in family medicine. A physician advisor, Dr. Poggenburg has been a hospitalist for 18 years, has worked in hospice for the last five years—and has volunteered in the anatomy lab for 25 years. She enjoys being close to family and friends, and her hobbies include swing dancing and caring for a 100-year-old home.