By Yung Chong Soon
This Wednesday morning started like any other day on the general medical unit as a final year medical student. I looked through the ward list, and noticed that Mary, a patient who I have been closely monitoring over the past three days, was no longer on the list. I was hit briefly by a moment of disbelief. Fearing the worst, I proceeded to ask my registrar, who was on his usual routine of checking bloods prior to the ward round. He turned around from his office chair and calmly mentioned that Mary had passed away in the early hours of this morning.
Due to the severity of her illness, we had already expected Mary to pass away over the next few days, but not this soon. My registrar appeared to relay this news with a rather calm demeanour, probably seeing this case many times before in the course of his medical career. I was taken aback by the news, but I forced myself to remain composed in an attempt to appear “professional” at that time. Reflecting on this, I question myself if I was trying to appear masculine in the presence of another male colleague who appeared to be calm and unfazed after recalling a patient’s death. Or was I trying to normalise the process of death, an uncomfortable topic among doctors that is rarely discussed, and perhaps even avoided?
Death can often be a harrowing experience, not only for patient’s families, but also to doctors. Having invested so much effort trying to cure a patient, we can see death as a failure of sorts, as many of us became doctors to help patients. The added responsibilities of being a final year student in caring for patients and being involved in their management plan certainly played a part in why I felt so strongly about Mary’s passing.
Mary was an 86-year-old lady who had been admitted over the weekend for excruciating abdominal pains of an acute origin. The surgeon on call during the weekend was reluctant to perform surgery on her as she had no obvious signs of a surgical abdomen. When I saw her on our Monday morning ward round, she could not even answer our questions despite being on strong opioid analgesia. I had not seen anyone in such pain as she had. My consultant performed an abdominal examination and found that her abdomen was peritonitic. In addition, she had developed acute kidney failure, which meant that she was quickly deteriorating. We ordered an urgent CT scan, which showed a small bowel obstruction. With this information in hand, the surgeon informed Mary’s family that she was unlikely to benefit from any surgery at this point, given the duration of her symptoms and her deteriorating kidneys which meant that end-organ-dysfunction was inevitable.
We consulted Mary’s family later that afternoon, with the presence of the surgeon and expressed our views that palliation will be the best management for her. It was then that I recognised Mary’s partner, a notable public figure. Through my eyes, I saw a side to him that we would otherwise never see on the media. He was a caring husband, prioritising his partner’s comfort during her last few days of life over anything else. It was a humbling experience, knowing that as medical practitioners, we are able witness meaningful events in patient’s lives, such as a birth of a baby or a passing of a loved one. The importance of patient confidentiality is crucial in this time, as a form of respect to patients and their families, and also to preserve their trust in us, as their treating doctors.
I came into medicine perhaps being a bit naïve, hoping to save every life, and I see myself face-to-face in a situation where this simply not possible. Five years of medical school certainly did enhance my clinical knowledge and acumen. However, there are still many things to learn in this profession that would only come with time, and dealing with death is one that I have just been exposed to. I did not expect myself to have such a strong reaction towards a patient’s death. Have I been too focused on passing medical school exams all along, that I had forgotten about the emotional component to this profession? There are some things that are not taught in medical school. While we are taught about palliative care management basics in medical school, the mechanism of death itself which I assume are important in identifying deteriorating patients are not well covered. For instance, we are often taught about medical conditions, such as pneumonia, but fall short of learning how it leads to morbidity and death for patients.
I have learnt a great deal from following Mary’s journey, combining what I had learnt from all the years in medical school, with many new lessons learnt along the way. The ability to recognise an unwell patient, learning to deal with clinical uncertainty and breaking bad news are lessons I learnt from Mary’s passing. There is an emotional component to our profession, and learning how to deal with those emotions is a part of our journey as future doctors. This is the greatest lesson that Mary has etched in me from her passing. May she rest in peace.
This article has been amended to remove potentially identifiable information in order to preserve the patient and her family’s privacy.