Death: An Emergency Doc's perspective

Since I started in the emergency services field back in 2003 I've seen more than my fair share of the deceased. Long haired teenage me trying to resuscitate a stabbing victim with unknown downtime with CPR alone. It was a huge rush back then and I can still remember the feelings of excitement, despair, hope, inexperience, and inadequacy. I look back now and realize that unfortunate man was unsalvagable. In these past 15 years working up the ranks from FF/EMT to college, grad school, med school, resident and now soon to be newly minted urban intercity gun and knife club battle hardened attending. I look at death now very differently than when I was a teenager or even as a medical student. Things have changed and those while I am much better at the job now there are still dozens I, and others are, hopeless to do anything about.

We learn about humanism in school and burn out (I'll write about this later). We are taught to empathize with our patients and their families. Some days its easy to deliver the bad news. Some families know its coming and it is not hard to make the shared decision to not pursue further painful, deforming procedures which we as the medical community will have no benefit. Still, we do what the family wants in other situations because of fears of retribution. I've had so many cases where the person in front of me is no longer a person anymore. They are a body. No life, no soul. Just flesh my team is sticking large catheters into, breathing tubes, and bones crunching with every chest compression. For what.... thanks everyone. Flatline and no cardiac activity on the ultrasound. We did all this to this person who in all probability if they could make the decision, would say let me go in peace and not mangle me if you know attempts are futile. It's so rare this happens though and honestly, I feel good when I can spare a family this trauma.

I'm going to let you in on a little secret. This can be one of the greatest gifts you can give your loved ones to spare them a lifetime of guilt. Take the decisions out of their hands. Me meeting your loved ones in a family room or at the bedside when major interventions such as breathing tubes and CPR are needed is not the time to be first thinking about them. Trust me, your doctor probably has a pretty good idea how the resuscitation is going to progress based on the story and who is in front of them.

If you have a discussion with your loved ones and make it clear what you would want in this situation then they are just the messenger. This is what you want. You do not want them to be the decision maker because no matter what they decide, they will always think and be wracked by guilt about what if they made the wrong decision on your behalf. Don't do that to your family. It's a hard thing to talk about but make your desires known so when I ask your loved ones they can be clear and confident they know your wishes. Better yet, talk it over with them and fill out an advanced directive or POLST (https://en.wikipedia.org/wiki/Physician_Orders_for_Life-Sustaining_Treatment). This way if another family member tries to contradict (yes it happens, a lot) there is clear documentation of what your wishes are. It can also define who will make these and other decisions on your behalf if they are not explicitly spelled out.

I got one of these a few months ago from my mother. I knew what she wanted because we've talked about it before. It's a somber thing to get in the mail. My mother's own mortality. It's an uncomfortable thing to think about. That's probably a major reason why more people don't have them. I thought about it for a few minutes and I'm glad she sent me a copy. My father is her proxy with me as the next after him being an adult child with the most experience in medical matters. This was a gift. A terrible morbid gift my mother had given me. She reminded me she will not be here forever but she wanted me to know what her last wishes will be in the event of her imminent demise in a healthcare setting.

I've had two deaths this week I've had to deal with, not unusual. One was expected.. elderly, sickly, expressed her wishes to pass because her siblings died this year. The other, 7 weeks old, unknown downtime, asystolic on arrival. Both are hard in their own way. Obviously the old and infirm is easier because family expects it. No one is ever ready for their newborn to die suddenly. It's those conversations that affect a family forever. Your words need to be chosen very carefully. Yelling, screaming, violence, anger. All are expected and there is nothing you can do except be there and be attentive. All this plus you have a department with other patients counting on you. It's really hard navigating this situation because your presence is needed in so many places at once. I can't spend as much time as I'd like with a family because of this and it pains me when I have to excuse myself. I can't potentially sacrifice more living for one dead. I need to accept what has happened and move on to my next patient who needs me as well. I can't take what just happened to me, that family, and department in with me to the next person. It's not their fault things just happened. They expect excellent care just like everyone else, I know I would. It's hard; very hard to move on so quickly sometimes.

We put up our defenses. We try not to let things get to us in order to keep at a high level of performance. We care about you, your loved one and we are sorry things didn't work out. Understand though that we cannot spend more than a few minutes with you because others rely on us too. We may cry with you, we may hug you if you want it. We may also express little to no emotion. It's our wall. It's how we stay sane in this crazy world and its one of the ways we cope and keep ourselves in check in order to move on to the next one.

In summary... death is hard for everyone involved.
Make your wishes known to your loved ones and write it down in an advanced directive and/or POLST
Understand that if you are the family member that your doctor does care, but they really cannot spend more than a few minutes with you because the department keeps on running... every minute, every day, 24/7/365.

Thanks for reading. Comments, questions?

Upvotes and resteems are appreciated. I hope this helps people in their lives heaven forbid they are in a similar situation.