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When We Don’t Want to Stop

Sklar, David P. MD

doi: 10.1097/ACM.0000000000000635
From the Editor

Editor’s Note: The opinions expressed in this editorial do not necessarily reflect the opinions of the AAMC or its members.

As the paramedics wheeled the patient into the trauma room, I heard the report: “Elderly man in motor vehicle crash. Wife dead at the scene. Multiple injuries. We can’t get a blood pressure.”

It was July and the team of residents were new to their responsibilities. So far, the day had been relatively calm with no serious problems. They were eager for a challenging case, and I could sense their anticipation as they approached the patient. As often happens in July, the residents gravitated to procedures they felt they could accomplish—one resident to the chest tube on the right side, another to the chest tube on the left, while a third positioned herself at the head of the bed in case an emergency airway procedure became necessary. Another resident used the ultrasound to look for bleeding in the abdomen as nurses and techs attempted to start more IVs. I watched to see which resident would begin to provide overall leadership for our resuscitative activities, but soon realized that no one was stepping forward. As I moved to the head of the stretcher to take charge, I saw that the patient was still conscious and trying to speak. “My wife is dead,” he gasped. “I don’t want to live. Please.”

Everyone in the room looked at me, waiting for my response. The scalpels were poised to slice open the chest. Now what to do? With the man’s barely palpable blood pressure and the obvious injuries he had sustained, he would die if we hesitated. I paused for a moment to consider what this man had just said and whether I should honor his request. What did he really want me to do?

As I considered our next steps, one of the senior residents proceeded to conduct the physical exam and shouted out his findings. “Probable bilateral pneumothoraces. Possible pelvis fracture. Femur fracture.” The man lapsed into unconsciousness. I decided that we had to try to save him in spite of his wish to die because it was impossible to know if he was thinking clearly with barely any blood pressure. Chest tubes and IVs went in. Quickly the patient was transformed from a person to a set of physiological parameters, blips on machines, and tubes with various fluids and medications. We transfused blood through one of them. The man lost his pulses and we began CPR. A resident intubated him. All of our procedures went well and the pulses returned. We tried medication to raise the blood pressure and poured in more blood. I wanted to do everything for him and to show the residents that we could make a difference and save a life. And yet the patient’s last words echoed in my mind: “I don’t want to live.”

As the man’s pulses disappeared again, our senior trauma surgeon, whom I had known for over 30 years, appeared suddenly at my side. He had been observing silently from the back of the room. We had been through many difficult cases together and I trusted his judgment. “It’s time to stop,” he said.

I took a deep breath. I did not want to face the fact that it was time to stop. “Dave, we need to let him go,” said the surgeon.

I tried to consider why I was so reluctant to stop. After all, the patient had asked to be allowed to die. Perhaps I was thinking of his children and their loss. Perhaps it was the new residents, so eager and hopeful. Perhaps it was the memory of a recent family that had exploded into howls of agony and anger when I told them their loved one had died. Finally I looked at my team and nodded. We recorded the time. The nurses disconnected the man from the monitors. I thanked everyone for their efforts and we discussed the next steps: informing the family, the call to the medical investigator, the paperwork. The team was already dispersing itself to other tasks: seeing other patients, answering pages, checking the computers. It all felt so mechanical and emotionless, lacking the tears that should have accompanied such a loss.

A little later, I sat with one of our residents as she talked with a member of the family over the phone. She was patient and caring as she described what had occurred and finally explained what would happen to the body. I complimented her afterwards on her communications with the family, and she explained that this was her first time doing this over the phone. We discussed the importance of having a plan before a conversation in which we give bad news, and I discussed some of what I knew about the literature on giving bad news to families and how stressful it could be even in simulated scenarios.1 A recent review by Shoenberger et al2 describes some approaches to improve death notification in the emergency department, which includes specific ways to improve the process and the incorporation of teams to provide the resources needed. Hobgood et al3 give advice for how emergency medicine residents can improve their death notification skills. In addition, Rosenbaum et al4 have published recommendations on the comprehensive education of students and residents to prepare them to deliver bad news.

As I moved on to care for other patients, there was something that continued to bother me, and I couldn’t quite put my finger on it. Was it the stress that the residents had just experienced? Certainly there was nothing in medical school that adequately prepares a resident for a case like this, which feels almost like being thrown into a raft going over multiple rapids and being expected to paddle and not fall out of the raft while an experienced guide shouts out instructions and tries to navigate the shoals. Fortunately, most residents get through this initial immersion and don’t drown, and in time they are able to guide the raft themselves. Simulation has provided an excellent bridge to prepare students for critical cases. Ziv et al5 have described how simulation helps educators find that delicate balance between the need for experience and the need to protect patients. In addition, simulation can reduce some of the stress that can occur in critical situations by giving students the opportunities to make mistakes and practice how to avoid them in the future. Park et al6 have described the use of simulation in the education of residents in the emergency department in a death scenario like ours and suggest that residents find it more useful than didactic presentations or role-playing.

Even though I knew the event was stressful for all of us, there was something else bothering me. Was it that the residents had not been better prepared for the experience of caring for someone who dies? Discussions about death—whether about patients who are fatally ill or injured and how far we should go to try to resuscitate them, or about patients with a known terminal condition and their need for palliative care—have been a much neglected part of medical education.

The Institute of Medicine (IOM) recently issued an important report7 identifying gaps in care at the end of life and the needs for better medical education. In this issue of our journal, several authors8–12 take up the challenge laid down by the IOM report and describe programs or innovations that could improve medical education in palliative/end-of-life care.

  • Day et al8 attempted to improve medical education through demonstrating the efficacy of Web-based education versus small-group-based education in palliative/end-of-life care and found that while students who had the Web-based training may not have been as satisfied as they would have been in a small group, their learning and self-efficacy did not appear to be different from that of the students who learned in a small group. Since faculty resources may be at a premium, this study’s finding suggests that Web-based learning could provide a valuable supplement to faculty-led education.
  • Tully et al9 describe the use of Google Glass to provide the unique perspective of recording a simulated encounter about the delivery of bad news from the vantage point of a patient; they also describe the use of traditional wall-mounted video recording. The majority of students found that the Google Glass recording offered additional useful feedback beyond that given by the normal video recording of the session.
  • Crawford and Zambrano10 describe how a clinical elective in palliative care for medical students instilled in them a sense of confidence and control over their interactions with dying patients and families that helped them later, when the students were in their postgraduate training. Those trainees also found they had gained knowledge and skills they could apply not only in caring for patients at the end of life but also in other areas of practice, and that their sense of purpose in medicine was strengthened.
  • Former Senator Bill Frist, a surgeon, and his coauthor, Martha Presley,11 note the problem of distrust between physicians and the public that has complicated discussions about end-of-life issues. In their New Conversations essay, they encourage increased emphasis on medical student and physician training in palliative care.
  • Neville et al,12 in their study of differences in predictions of futile care for critical care patients, provide insight into some of the uncertainties about prognosis for death that can contribute to confusion and mistrust between physicians and patients’ families. Fellows tended to predict that more patients were receiving futile care than did attendings, and more of the fellows’ predictions ended up being incorrect, suggesting that accuracy in such predictions develops with experience. This study also demonstrates how challenging it can be to accurately predict futility.

Taken together, these reports encourage honest and informed conversations between physicians and patients prior to their last days that would provide guidance for their families and caregivers concerning the patients’ wishes.

Perhaps, had my patient had such a conversation, and had the results been available to me, we might have been able to chart a course of care that he had chosen. However, this man’s injury was sudden and unexpected, and neither the care nor his wishes were predictable; events moved quickly, overtaking our usual routine. I had been compelled to make a split-second decision about the patient’s capacity to make an irreversible decision, and had opted to continue onward to try and save his life, which led to numerous medical procedures that ultimately did not change the outcome. But we did not know that at the time.

For that reason, I have come to think that attempting to save the patient was, initially, the correct decision. Even so, right after the unsuccessful resuscitation, something felt missing. Everyone except me had left quickly. There was only our patient’s body in the middle of the room as the housekeeping staff arrived and began cleaning. All the buzz of organized activity had disappeared, replaced by an occasional student darting into the room to retrieve a white coat or a nurse seeking a notepad. It reminded me of a stage after a concert, without the lights, the music, or the audience. The silence was eerie and upsetting. I now believe that almost everyone’s immediate dispersion to attend to a myriad of other activities was partly to avoid that silent room and the feelings of failure, fear, and powerlessness that the body lying there engendered.

I wonder whether caregivers could learn how to transform the upsetting emotions surrounding the death of a patient in the way that first-year medical students have done: with gratitude ceremonies for their cadavers.13 In these ceremonies, students, teachers, and family members join to honor the dead, their lives, and their contributions to the education of future medical students. These deaths take on a special significance and power. When I was a medical student, our cadavers were sources of much anxiety and mystery, but this new kind of ceremony has changed attitudes and behaviors. Could we do something similar for those patients who die in spite of our resuscitative efforts and from whom our residents and students learn so much through their participation in the care of those patients? Perhaps the cadaver ceremonies could point us in a different direction, away from feelings of failure, fear, and powerlessness. What might the effect have been if we, as a group of doctors, nurses, technicians, and students, had taken a moment together after concluding the resuscitation effort to honor the life that had just passed on and the connection we had to it? Would such a moment have replaced our upset feelings with a sense of group support and solidarity? We had the privilege and responsibility to be present during the last moments of a man’s life. He was someone’s father; someone’s husband. His life had a meaning. We got to hear this man’s last words, feel his flesh beneath our hands, and observe the arrival of death.

Sometimes we can save a life and sometimes we cannot. But even when we cannot, we still can take a moment for reflection when a patient dies. We can stop what we are doing, recognize that we have been part of something profound, and reflect upon that person, that person’s life and passing, and our connection to him or her before we begin the paperwork, the cleaning, the telephone calls, and moving on to the next patient and the notification of family. I think the way we behave after an unsuccessful resuscitation should be linked to how we discuss end-of-life options with patients and families, how we inform families about the loss of a loved one, and how we provide palliative and hospice care. The link is respect and compassion.

This comprehensive approach to death could help us begin to accept and better integrate death into the medical education and health care delivery system. By beginning to have conversations about end of life with patients and families, becoming knowledgeable about the resources for palliative care and hospice care, learning how to communicate about death with families considering when and how to stop a resuscitation, and acknowledging and respecting the dead, we can begin to see death as one of many transitions in a patient’s lifetime, one deserving the same attention in our medical education and care delivery systems as curative medicine. And when physicians feel the gentle hand on a shoulder as I did, accompanied by the words, “It’s time to stop,” they will be better prepared to recognize that hand as an ally rather than a threat.

David P. Sklar, MD

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© 2015 by the Association of American Medical Colleges