Apologies in advance for the death-related themes… In my line of work it’s difficult to avoid or minimize. Roughly one-fifth to one-quarter (20-25%) of all patients admitted to a tertiary care intensive care unit die.
One of the challenges of health care and I strive to convey this to my residents is to appreciate the uniqueness of every individual human being for whom we care. It is easy, in the hustle and bustle of a busy practice, to gloss over the humanity and focus on the technicality. A quick succession of patients means it is often easier to refer to the patients as bed or room numbers or as diagnoses rather than by their name. Bed 36 or room 212A can evoke more in a healthcare provider in terms of detail than Mrs Smith. I try to insist on names and to encourage others to do the same, but, again, in a busy practice, it is easier to do what it is easier.
I try to encourage myself and others to know at least one detail of a person’s life. I feel that this is important as a way of anchoring the patient in our minds, rather than seeing the patient as a case. The less a patient is able to communicate, the more this becomes important. The ICU – and modern hospital practice in general – is a place for procedures. It is a place where things get done – tubes, lines, devices, surgeries ..etc. The more a patient is unable to communicate, the more important this element becomes – ensuring that we remember that their is a unique individual human being with a personal unique life story. Otherwise, we can easily forget that we are doing these things – lines, tubes, procedures ..etc. for the patient rather than just to them.
Ensuring that you have a connection, however, small, with the person who is the patient does have its drawbacks. When the outcome of a hospital or ICU stay is death, having invested even a small part of you in the patient can make it so much more difficult to care for them at the end of life. Imagine having someone known to you (I won’t say “close to you”) die every week. Difficult.
Two incidents stand out in my mind that I think I will remember for some time to come. One occurred two years ago and the other just last week. The two could not be more different and in a way they exemplify this notion that every individual is unique. The first patient was an elderly woman – in her late 70s I think who had just relocated to London from elsewhere to be closer to her family. She had not yet made any friends and her family was out of town on vacation when she developed a sudden chest infection and had to be brought into hospital via ambulance. She was assessed in the emergency room and was too unstable to be admitted to a regular ward bed and so was transferred to the ICU. The illness progressed very quickly and it became apparent she would not survive. We finally located the family and it was obvious they would not be able to make it back in time. The patient’s daughter could not bring herself to hear about her mom’s condition and I spoke mostly to the son-in-law. The patient’s daughter finally managed to wrest every last bit of courage in her being to come back on the phone. The only thing she could say was, “please don’t let her die alone.” I assured her we wouldn’t. I went back into her room and tried to do my best to talk to her about how much her family wanted to be there for and with her. I don’t know if she could hear. I felt some kind of conversation was important, but it was hard to sustain a monologue and so eventually I think I just held her hand and waited. I don’t remember it being long – I think she passed away over the course of 20 or 30 minutes.
The second story is about a much younger person – a woman in her 30s who died surrounded by family. It is still a little too fresh to write about, but it instigated these reflections. Whenever we go through these experiences in the ICU, and as I mentioned above, we go through them with some regularity, I am reminded of a line from a poem by the Scottish poet Edwin Morgan . I first learned this during my GCE O Levels (Thank you, Mr Dickson): “These were next to him when he fell/and must support him into death.”
We have the privilege of being next to people at the most important events of their lives – births, deaths, illnesses and cures. Some may fear the emotional investment that is necessary to provide that support. There is a certain fellowship that develops among the people who care in this way and that is also one of the privileges of practicing with caring professionals.
Death in Duke Street – Edwin Morgan
A huddle on the greasy street –
cars stop, nose past, withdraw –
dull glint on soles of tackety boots,
frayed rough blue trousers, nondescript coat
stretching back, head supported
in strangers’ arms, a crowd collecting –
‘whit’s wrang?’ ‘Can ye see’m?’
‘an auld fella, he’s had it.’
On one side, a young mother in a headscarf
is kneeling to comfort him, her three-year-old son
stands puzzled, touching her coat, her shopping bag
spills its packages that people look at
as they look at everything. On the other side
a youth, nervous, awkwardly now
at the centre of attention as he shifts his arm
on the old man’s shoulders, wondering
what to say to him, glancing up at the crowd.
These were next to him when he fell,
and must support him into death.
He seems not to be in pain,
he is speaking slowly and quietly
but he does not look at any of them,
his eyes are fixed on the sky,
already he is moving out
beyond everything belonging.
As if he still belonged
they hold him very tight.
Only the hungry ambulance
howls for him through the staring squares.