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Dealing With Death: Unavoidable Med Student Rite of Passage
When Kristina Newport, MD, was a first-year medical resident doing a night shift at a small veterans' hospital, one of her patients, who was very sick with multiple chronic diseases, made the decision to forego further treatments.
She found herself in a 'profound discussion' with her senior resident and attending physician about their patient. Newport recognized a major shift from what she was used to.
'It felt like such a contradiction of what my job was…just thinking about the possibility that we would let him die naturally,' she said.
As the night wore on, she checked on the patient often to make sure he was comfortable and peaceful. Nurses reassured her that the team was doing the right thing.
Ultimately, this patient died peacefully with his daughter sitting next to him. For Newport, the experience was 'remarkable' and transformative and led her to go into palliative care medicine. It was also so different from many of the patient deaths that followed, where the teams she was part of tried many interventions to no avail.
'Our job is to alleviate suffering,' Newport told Medscape Medical News . 'And sometimes that means allowing people to die naturally. And so, my first experience really cemented that and helped me to understand how valuable it is to play a therapeutic role in that situation and allow that process to happen.'
Doctors and medical trainees experience a patient's death differently, said Newport, who is now chief of Palliative Care Medicine for Penn State Health in central Pennsylvania and is chief medical officer for the American Academy of Hospice and Palliative Medicine.
If someone has had a friend or loved one die, 'that will change how they experience their first time that a patient dies,' she said. On top of that, the intensity of dying and death manifests in different ways.
'Sometimes death is very quiet,' she said. It can happen while a trainee is making small talk with the family. 'And other times it's really dramatic, where somebody has had a trauma or a cardiac arrest and they are pronounced dead after an attempted resuscitation.'
The response and experience of the medical trainee might be different depending on those circumstances, she said.
'…It is a pretty profound experience, and something that if it's the first time the trainee has ever experienced someone dying, it's important to allow them to have those feelings and just recognize that it really is something unique that they are a witness to.'
'Medicine Isn't Only About Interventions'
When a patient dies, it can be disorienting for medical trainees, Raya Kheirbek, MD, MPH, said in an email.
A patient death can feel like a failure even when it isn't, said Kheirbek, chief of the Division of Gerontology, Geriatrics, and Palliative Medicine at the University of Maryland School of Medicine in Baltimore. A trainee can feel fear, helplessness, and even shame.
Being present matters, she said.
Raya Kheirbek, MD, MPH
'Medicine isn't only about interventions or cures; sometimes it's just about bearing witness. Sitting beside someone in their final moments, listening to their fears, holding a hand when there's nothing left to do — these acts carry weight…,' she said. That is the practice of medicine, too.
When a patient dies, 'don't rush through it. Don't turn away from the discomfort…,' Kheirbek added. 'You don't need to have the perfect words.' Families remember whether you were present, honest, and kind, she said.
'Real Doctoring'
'Every physician has a first patient who dies, and it's often sad and wrenching. And it's an initiation into real doctoring,' said Ira Byock, MD, professor emeritus at Dartmouth's Geisel School of Medicine in Hanover, New Hampshire.
It can be draining to take care of dying patients, he said, but 'there are more than a few times when we can also be filled up by the privilege and profound meaning of accompanying somebody during these intimate times of their lives.'
Ira Byock, MD
Byock directed the palliative care program at Dartmouth's Geisel School of Medicine for 10 years and is the author of a number of books including Dying Well and The Four Things that Matter Most .
Most of the time, doctors provide care by diagnosing and treating physical ailments, Byock said. 'But sometimes doctoring requires being present, showing up and leaning forward, and attending to their [the patient's] physical, emotional, and social well-being.'
Process With Others
After a patient dies, pay close attention to how your mentors approach these moments, Kheirbek said. 'Ask them how they process it, what they've learned over time. There's wisdom in those quiet conversations.'
It may be particularly challenging for trainees who were peripherally involved in the patient's care, Newport said. 'You don't really understand why the person died, but you're expected to just move on because you weren't closely involved. And so, I think those situations are some of the harder ones.'
She encourages trainees to ask their senior residents and attendings questions like, Can you help me understand what happened? Or why did we do it the way we did? If they're not in an environment that is conducive to raising these questions, they can seek out someone else to help them work through things, she said.
There may be times when there were mistakes or questionable actions that occurred before a patient died, and this 'can really lead to some complicated feelings about what happened,' Newport said. In those situations, it is important to talk through that because it can be 'a very burdensome feeling' if the trainee feels like something they did contributed to the patient's death, she said.
Kayla Fresco, MD, who just completed her third year of residency in internal medicine at Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, has questioned herself after a patient died.
Kayla Fresco, MD
'I think that's been one of the things that's been hard…to sort of overcome because you have all these thoughts. There's on the one hand, 'What did I do objectively? Did I do everything right in the code?' And you're sort of second-guessing or 'Is there something I could have done?''
Fresco has found it most helpful to debrief with others on her team after a patient death.
'And it's something that I've continued to appreciate in other code situations throughout training,' Fresco said.
Byock advises young trainees to normalize the expectation that they will care for patients who die. 'Don't let it devastate you. Let it impact you,' he said.
There are also rituals that healthcare providers can conduct to create positive meaning. Kheirbek makes a point to pause after each death. 'I stay in the room, even briefly. I say their name. I acknowledge their life,' she said. If the family is there, 'I try to meet them with honesty and presence.'
Newport keeps the names of all the people who died under her care, and she reaches out to their family members.
Just the simple act of 'validating and making space for the loved ones is therapeutic,' she said. You can say to a patient's family member something as simple as: 'This is really sad.'
Fresco tries to slow down the process after a patient dies. She waits a little longer than is typical to perform a death exam. And then while performing it, she always uses the patient's name 'to really respect that person and…show respect for their family and recognize the value of their life, no matter what the medical outcome is,' she said.
'When you're faced with it [death] that close, it makes you question sort of your own mortality,' Fresco said.
Fresco has learned that grief can take many forms. Some of the most difficult situations are when the family is not prepared for the patient's death. She once took part in an hour and a half long code for a 35-year-old patient. When the team stopped compressions, a family member ran into the room and yelled at them to keep going.
'Part of the process as a provider grieving is me knowing that the family is grieving and that I shouldn't take those things personally when the family comes and yells at me,' Fresco said.
Over time, medical trainees may become more comfortable in dealing with death, 'but…it always still has an effect,' Newport said.
'I think the way that it's changed for me is that rather than it being a scary experience, I view it more as a, a very, almost sacred or very precious experience to be able to…be with people in their final moments,' Fresco said.
Yet it's also sometimes overwhelming and exhausting, she added.
Don't Neglect Yourself
It is essential for medical students and residents to take care of themselves when a patient is dying and after death has occurred, experts said.
'We ask a lot of our trainees. They're human beings, and it's important that they maintain their humanity in this space,' Newport said.
Medical trainees should not feel like they have to hide their emotions, particularly the first time they experience a patient's death, Newport said. 'It's totally normal to have any range of emotions.'
She recommends trainees think about a twofold response — how you can be there for the patient and family members and also make space for your own emotions.
'If we don't make space for our own sorrow, we risk becoming detached, even numb,' Kheirbek said.
