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Reflections

The Present Concern

Frush, Benjamin MD, MA

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AJN, American Journal of Nursing: August 2020 - Volume 120 - Issue 8 - p 72
doi: 10.1097/01.NAJ.0000694604.25353.d7
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Abstract

“Let's call it. Time of death, 3:24.” As the intern on the team tasked with performing chest compressions, I am grateful for the critical care fellow's permission to cease. It has been a draining week in the medical ICU, as Mr. Smith is the fifth patient to die on our team since my rotation began. Having witnessed few patient deaths prior to beginning residency, I am surprised by how readily I have been able to compartmentalize feelings of anxiety, fear, and sadness.

As I make my way out of Mr. Smith's room, I notice his nurse, Julie, sobbing quietly in the corner. It occurs to me how strange it is that the act of mourning in the face of death should seem deviant. Bereft of words, energy, and the wherewithal to offer true comfort, I clumsily hand her a tissue box and turn to exit.

“His daughters were my age—that's what makes it so hard. He lived on a farm and wanted so badly to get back there to die.” Julie's words at my back stop me in my tracks. I realize now how little I knew about Mr. Smith. Perhaps he mentioned his daughters or the farm to me when I penned his admission history and physical my first night on the unit; if so, I likely would have deemed this extraneous to the unknown cause of his acute hypoxemic respiratory failure.

I sit for a few minutes with Julie and hear her recount parts of Mr. Smith's story that she has gleaned these past three days at his bedside. She says that before he was intubated, when he was able to speak with her, he was a tough patient, but in the right ways. He always wanted to know which medications he was receiving and any changes in the plan that he hadn't been apprised of on rounds.

I say nothing as Julie tells me how these deaths never get any easier, even five years into the job. But then again, she says, she would have it no other way; the day the tears stop is the day she knows she has lost an important part of herself. I nod quietly, offer some platitude about allowing ourselves to be sad, and slink back to my workstation.

As I sit down and prepare to work on Mr. Smith's death documentation, I find myself beset by an unexpected and powerful sense of envy toward Julie. What I would have given at that moment to have heard Mr. Smith's story well enough to be moved by his death, to have the privilege of knowing him enough to be pained by his passing.

Ask physicians how they understand the nature of their profession and most will answer by describing what they do. Make diagnoses, perform procedures, write orders. These are important parts of the job, to be sure. Yet what I have come to learn in my short time taking care of patients like Mr. Smith is that, just as important to them as effective diagnosis and intervention is the desire that those caring for them might simply be, as in, be present. They want those tasked with their care to see them, to listen to them, to perceive them as something other than a 64-year-old male with a medical history of heart failure presenting with acute respiratory failure. They want to be recognized as people with particular stories, of which their illness is a parenthetical, not the main content.

The theologian Stanley Hauerwas recognizes this point as he argues that, amidst a medical culture that strives so hard to do, to fix, to cure, the constitutive role of the physician ought rather be understood as offering presence in the face of suffering; as caring, even (and especially) when cure is not possible.

And yet my experience in residency is a far cry from the vision that Hauerwas offers. There are too many patients with too many problems, too many notes to write, too many pages to respond to, too many consultants to call. As an intern it felt impossible to offer presence, given time constraints; as a senior resident, when I now have time, I've found that the efficiency-crazed milieu of modern medicine has dissuaded me from that desire too often.

While Julie has her own legion of responsibilities, it is individuals like her who recurrently remind me of the centrality of this moral commitment to presence when I'm tempted to find my vocational identity elsewhere. I am grateful when such witnesses testify to the enduring worth of Mr. Smith and those like him—and hold to account those of us who would too often forget.

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