LAUSR

Practicing medicine is full of firsts: the first time someone calls you “doctor” and the first time a patient thanks you for saving their life. After those moments, you leave the hospital remembering why you went into medicine. You like to help people. Sometimes that means curing or easing someone’s suffering. Sometimes that means helping families cope with terminal conditions. You want to save the world 1 person at a time. And then, of course, there’s the first time you call time of death. I remember every moment leading up to the first time I called time of death. During sign-out that day at a children’s hospital, the senior resident discussed newly admitted patients with me. She breezed through the list and then told me about a patient whose family had requested “Accept Natural Death.” No chest compressions, no cardiac medications, no intubation. The senior resident never mentioned that this patient could die that night, and I did not think to ask. So, I was surprised to receive a call from my intern that this patient had hypoxemia with the maximum amount of oxygen flowing to his lungs. I knew he was going to die that night. I felt inadequate and underprepared. I entered the room as the nurse asked my intern, “Did you call your senior resident?” That “senior” was me. When the nurse saw the patient’s condition worsen, she had called the intern. When the intern saw this child developed cyanosis, she had called me. What I wanted to do was call my family—I needed a reminder to be strong. Instead, I entered the room and introduced myself to an anxious mother. The patient was unresponsive and gasping for air. His oxygen was low and not budging. His systolic blood pressure was 60 mm Hg, barely high enough to squeeze enough blood to his fingers, toes, and brain. The mother thought he was not responding because a new medication for sleep was started the night before. However, I knew this medication should not cause a child with a chronic illness to be unresponsive and have hypoxemia. I explained what each vital sign meant to his mother. I explained that his blood was not getting to his brain, and his body was holding on to dead air. I explained that he was gasping for clean air and that a little bit of morphine would help provide her child more comfort. Then she asked me a question that will haunt me forever: “Is my son going to die tonight?” Chills. Everyone silenced, and the beeping faded away. “It looks as though he may,” I replied. At that moment, the mother understood the severity of her son’s illness, and I felt like I became a physician. The child continued to reach decompensation, and within an hour, I was called to the bedside. I took a deep breath—for myself and for the child—and entered the room. I explained that I was going to do a physical examination. I listened to his empty chest for a full 2 minutes, felt no pulse for a full 2 minutes, attempted to constrict his pupils, and pinched his shoulder blades without eliciting a flinch. Then, I called time of death. I apologized for the family’s loss but could not fathom what they had been through. After that, I took a moment to cry and call my family to tell them I love them. I brought together the nursing staff, respiratory therapists, my intern, and the medical students who had been in the room that evening to debrief. I was deeply sad, and knew I was not alone in this. Together we discussed the patient and made a plan. I filled out the appropriate paperwork and wrote my first death note. Then I asked if the patient’s family wanted to have handprints and footprints of their beloved son. They said yes, so I searched the hospital for the kit. During the day, Child Life specialists take care of these requests, but there is no Child Life at 1:48 AM during the holiday season. I reentered the room with blue ink and paper and respectfully stamped the patient’s hands and feet. I gave this family back a piece of their son after so much had been taken away. As a physician, I felt humbled and disoriented because I did not go into medicine to pronounce people dead, much in the way parents do not have children to watch them die. And, as a person, it made me miss my family. The next day, I left the hospital in tears. I tried to sleep during the day, knowing I had to return later that night and be fully present yet again. My sleep was disrupted by my tears as I awoke from dreams of getting the call over and over from my intern. It also happened to be my birthday, which is just another day in life’s progression, but I felt like I became an adult that day. I continue to reflect on why I felt so underprepared in this situation. People die. This is something that will happen in every person’s life. I have hugged my own grandparents for the last time and brought flowers to freshly dug land and patches of earth that are weathered with time. In those moments, it is OK to feel and reflect on lives lost. After all, feeling is part of the human recipe. And just because we are physicians does not mean we are not human. We feel deeply, and, so we can continue caring for others, must stifle our feelings until there is time to reflect. But, what if we do not find that time, or push it away when it presents itself? Does this environment make us less human or, instead, instill a resilience that makes us better versions of ourselves?