During my third year of med school, the deaths of my patients have been entirely mysterious to me. They are dispassionate words on the medical record or casual condolences passed in the workroom. Sometimes, they happened even without my knowing. “How could you not know?” A friend teased. I reached reflexively for excuses. I hadn’t known because the patient had passed away on a Sunday when I had not been on call. The next day, the death was old news and no one thought to tell me since she was not a patient who I had cared for on a regularly. It took me two days to notice that a new patient had settled into her old room.
This woman who passed away had not been my patient because “she’s not interesting,” my supervisors had said. She had been “comfort measures only” so there were no vital signs to record, no labs to interpret, no procedures or medicines to debate. We spared her even a perfunctory physical exam and visited her room only to whisper words of reassurance. During her final days, her soft, aged face stared deep into the distant wall as I was quickly ushered into other rooms where I could perform the prescribed tasks of a third-year student: seeing and reading.
In only a few months on the wards, I have seen and read so much. Each day is a slew of new rashes to examine, murmurs to auscultate, radiographs to interpret, numbers to crunch, procedures to watch and, in concert with all this, an infinite number of readings to peruse for each of these experiences. See more. Read more. Every day.
Yet death is conspicuously missing from this curriculum. On the first day of our third year, we were promised an introduction into every corner of medicine and the human condition. Yet despite my curiosity, I have not seen death. Each code blue I scampered to has been successful, thankfully, while the fates of a handful of less fortunate patients were signified only by a “Notice of Death” in the electronic record I scanned each morning with breakfast. These happened in the intensive care unit six floors down from where I worked, or at a nursing home far away, within days of our hopeful goodbyes at discharge. Each death passed quietly in my life – the sounds, sights and smells of death conspicuously absent from my morning readings of their medical records.
One of my mentors told me that I should try to be present for my patients’ deaths. She was chagrined that students are scheduled for a week of night shifts on obstetrics to see births while given few opportunities to appreciate death. Instead, I scroll through records of prior patients each morning as if reading about tragedies in a far off country, described with far less pathos than in any daily newspaper. I hunt through the progress notes from the days before, struck but how little foreshadows each patient’s fate. Each day is the same: an onslaught of numbers followed by a short problem list, none of which hint that my patient seemed to the overnight intern “on the brink of death.” After the fact, there is little evidence of how it happened.
I still have not seen death. In the absence of the rich documentation I have come to expect, I cannot read about death. The day that I watch a patient die will be an accident in my curriculum.