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No textbook necessary

Bertrams, Daniel MMS, PA-C

Journal of the American Academy of Physician Assistants: March 2017 - Volume 30 - Issue 3 - p 1–2
doi: 10.1097/01.JAA.0000512230.08185.1f
Mindful Practice

Daniel Bertrams is an instructor in the PA program at Wake Forest School of Medicine and a PA in the trauma intensive care unit at Wake Forest Baptist Health, both in Winston-Salem, N.C. The author has disclosed no potential conflicts of interest, financial or otherwise.

Tanya Gregory, PhD, department editor

Although each newly certified PA faces his or her own set of unique challenges, it also is likely true that all new providers have certain challenges in common. Some that come to mind are a huge learning curve, time management, and periodic (okay, maybe more than periodic) feelings of inadequacy. One challenge I have been thinking about recently is a patient experience that had me questioning my medical prowess as well as my duty of nonmaleficence.

The patient was a middle-aged man who had been in a car crash. When he first came in, he had altered mental status and obvious facial trauma, and he was not moving any of his extremities. Imaging revealed acute subarachnoid hemorrhage, bowel injury, facial fractures, cervical spine fractures, and severe narrowing of the upper cervical spinal canal. He underwent an emergent exploratory laparotomy as well as a cervical laminectomy and fusion. Ultimately, he returned to our ICU intubated and on vasopressors.

The patient had a wife and two adult daughters. As expected, they were distraught over his physical condition when they first arrived. I couldn't help but feel the desperation teeming from their cries. Even though I routinely see patients with all sorts of invasive lines and tubes and hooked up to monitors tracking vital components of their clinical status, I cannot fathom the initial shock of seeing a loved one in that condition. I began to explain each piece of medical equipment to the family, to try (“try” being the key word here) to make the circumstances seem less scary. After a lengthy discussion, the family seemed somewhat more at ease, at least as much as possible considering the situation. The discussion had gone well, and I felt as if I had made a real connection with them. I left that day with a feeling of warmth and accomplishment, along with a long list of subjects pertaining to this patient to research that night.

The patient's hospital course was long and tenuous. For a brief period in the beginning, he was able to communicate by shaking his head “yes” or “no.” When discussing nutrition in the ICU, the patient's wife and daughters jokingly said all he would want is an enormous Mountain Dew, his drink of choice. I wished so badly that he could have a gigantic, ice cold Mountain Dew. Instead, I have vivid images of his face as I tried several times to place a feeding tube. He had these piercing, bright blue eyes that silently screamed at me, telling me to stop. I felt as if I was torturing him. He eventually developed pneumonia, and his hemodynamics became increasingly unstable. He went into kidney failure and required chronic renal replacement therapy. He developed acute respiratory distress syndrome and ended up on extracorporeal membrane oxygenation. The number of personally invasive interventions and large pieces of medical equipment in the room was going in the wrong direction.

He waxed and waned each day, but his decline seemed steady and inevitable. Every day I would wrack my brain thinking of different ways to try to make him better. The days became weeks, and then the weeks turned to months. Several family meetings were held to establish goals of care. The family initially insisted that he be treated aggressively using all means possible. However, the wife appeared more and more uneasy as time progressed. Maybe she doubted she was doing what was best for her husband, or maybe it was the result of the stress she had been enduring. They had never discussed this type of situation. I don't know how I would react if I was in her position. Things always seem more objective from the outside looking in.

The patient eventually received a tracheotomy. Even though it was another surgery, we felt like we won a battle in a long and grueling war. Then one day I came in, and he was wide awake. We were again able to ask him “yes” or “no” questions, and he could mouth words to us as well. That he could communicate with his family again lifted everyone's spirits. I struggled not to tear up watching the first interaction between husband and wife after months of unimaginable anxiety.

Clinically, he was quadriplegic, ventilator-dependent, and still requiring intermittent dialysis. It was not too long before he began to express his true feelings on the situation. I remember it clearly: with a slow, exaggerated movement of his mouth, he said, “LET ... ME ... DIE.” It was startling. It was time for another family meeting, but unlike with previous meetings, the most important person involved would be present.

This meeting was brief, but it was by far the most definitive. The patient and his family decided to withdraw life-sustaining measures and switch to comfort care. Maybe it was the months of emotional turbulence or maybe it was the fact that the patient's wishes were finally communicated, but there was this brief, intense moment of relief and almost tranquility that enveloped the room once the decision was made. Pain and grief accompanied this decision, but no one had doubts or regrets. The patient and the most important people in his life had chosen what to do, and for the first time since his arrival, there were no more decisions to be made.

I couldn't help but think that I and the team had failed this family in some way. We missed something. There was something more we could have done. The more I reflected on the situation, though, the more I realized that even if a patient has a bad outcome, it does not mean the clinician has failed. There are so many different facets to the care that we provide. We medically treated the patient to the very best of our ability, but we were never going to be able to return him to the life he wanted to live. The best thing we did as clinicians didn't require a textbook or medical knowledge at all. It was to provide compassion to the patient and his family, as well as get him to the point where he could communicate with his loved ones during the last days of his life.

Death is an especially common reality for many healthcare providers. We fight it every day, and sometimes, inevitably, we lose. But death also is an opportunity. We can use it to provide patients and their loved ones with a deep, meaningful experience in the very last chapter of life. Patients may die, but their families will remember the final experience they had with their loved one for the rest of their lives. The death of a loved one can leave families at peace, or it can leave them with anger, regret, and a negative perception of the medical community.

We are all guilty sometimes of thinking of our work as “another day at the office,” but whether it is a minor procedure or the death of a loved one, we must remember to consider the patient's or family's perspective. Finding ways to offer love and compassion can provide at least some level of solace for both providers and patients in the face of death. I know it helped me when I reflected back on this case. I'm not exactly sure where he is right now, but I like to think he's somewhere warm, sipping on an ice-cold Mountain Dew.

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