Certifying death and losing patients

Since starting my career in medicine, I have been asked to certify death on many occasions. The first few that I was called to see were in hospitals as part of a ward team or even after hours as the intern covering surgical or medical wards. Often, I had not known these patients for more than a few days and had sometimes been already non-interactive for this time. Therefore, I felt little sense of personal connection. When called to certify, I was merely formalising the passing of the patient. I would dutifully listen for heart sounds and breathing for one minute, check pupils and response to pain. Of course there were a few challenging cases…

In the country as an intern, I was called at 3am to see a patient. Of course I missed the nurses first few sentences as my brain spooled up on the phone in bed. All I heard was “…so he’s fallen and there’s a large laceration to his forehead.” My response was something along the lines of “ok, so I guess I’ll come in and stitch him up?” The nurse replied “didn’t you hear me, I said he’s dead.” An important reminder for those calling doctors in the middle of the night, summarise the case at the end of the call! At any rate, this inpatient had advanced metastatic cancer and got up out of his bed and fallen in a separate corridor. My junior tired doctor brain didn’t know whether the coroner needed to be called. So we called the office and they said not to worry, just take some photos and certify. This was the first time I’d had to assess and certify a death where the patient hadn’t passed away peacefully in bed.

On another occasion earlier in my career on the hospital ward, some of the patients family wanted to be present at the certification. I had to quickly think about how to inflict a painful stimulus in a non-dramatic way. Surely sternal rub or supraorbital pressure was out. I fell back to nail bed pressure with the cap of my pen. So after checking for a radial pulse, the pain response was covered discreetly. Then came the difficult part, what should I say as I leave and walk out the door? Sorry for your loss? I didn’t really know the patient, so it would be hard for it not to sound forced.

Interestingly working in a country town last year presented a solution to that problem of what to say. But it also raised a bigger issue. By living and working in a small community, you invariably get to know your patients a lot better than in a large hospital. You see them every fortnight or month in the clinic and then in the other times down the street, at the footy and supermarket. Some were even my close neighbours and friends. You learn their little nuances and build up something that draws me to general practice, rapport. You are part of the best and worst of their lives. Watching a new treatment work wonders for someone all the way through to the end of life. I saw many of my neighbours, patients and friends pass away last year. But unlike city practice, as a rural doctor you are the one to certify and see the final state of your patient that you have got to know. Many times, the last thing I remember of these people is certifying a lifeless body in front of me. I want to remember the laughs in the clinic, seeing them moving better with a frame in the community or having a beer at the pub. It is the burden that rural doctors take on when this happens. For this reason, I always ask the family if I can get a copy of the little funeral booklet that often tells the amazing life story of your patient. It helps me to replace the last image and moments with them in the hospital with a vibrant history and imagine the living patient again.

But it is not all doom and gloom in the country. Having been the patients doctor and friend for a longer time has allowed me to say more to the family when it comes time to edging out of the door. Previously an awkward moment of ‘what to say’ was now backed up by rapport and the patients story. I will often say: “I’ve known and looked after  ‘John’ for the last 10 months now. It has been a privilege to be his doctor in that time and I’m going to miss him in the clinic.” So the extra emotional burden of losing your patient in fact helps to better talk to the family with compassion. It is real as often you are grieving as well. I’m looking forward to working in the country and being a part of the community, but how will I deal with the constant loss? If any GPs would like to comment, I’d be very keen to hear your thoughts.



  • rfdsdoc

    great post!
    My most rewarding GP experience has been providing palliative care to a dying man in his own home with his family around him. much more humbling and uplifiting than all the RSI, critical care and resuscitation in the years in between

    May 31, 2013
  • Thank you for writing such a beautiful and loving post about your feelings as your patients experience the end of their life. My former husband is a minister. I remember when we would move to a new parish and he would have to perform a funeral for a member we hardly knew. It was awkward.

    Once when he was very young to his role as the Minister began to cry while in the middle of a funeral for a beloved gentleman. While he was terribly embarrassed the widow was deeply touched.

    Your community is so fortunate to have you as their physician. Having the opportunity to really know your patients as you do is becoming so rare for so many of us.I wish you continued success as you provide for those you serve. I hope this is the best year you can experience.

    May 31, 2013
  • Palliative care & ICU – two most rewarding and ‘as real as it gets’ rotations as a junior doc

    …and translate well into value for the rural doctor

    May 31, 2013
  • I found one of the the best bits about working in a small country town was palliating patients I knew well, and I knew a lot of their family. I’d often treated them in the nursing home and there was much more trust and a pre-existing relationship, which made having end of life discussions much easier. It also gave family members an opportunity to come to see me in clinic and ‘debrief’ about the death if they had any questions or wanted to understand what had happened, especially in a non-cancer death like a gram neg sepsis in an elderly frail patient. I think it’s one of the most rewarding things to do as a doctor, and I’d love to do some more pall care training down the track to be better at it!

    May 31, 2013
  • JoAnn Jordan

    Beautiful post! I too live rural. Having my physicians know me as a person, what is important to me, and my lifestyle has helped build my sense of trust and of quality care they provide. As a music therapist, it has also allowed my clients the option of these closer relationships.

    Living rural may not be for everyone. Being in dual relationships may not be appropriate for all professionals. But, it is a reality for many and it has its pluses as your post demonstrates.

    May 31, 2013
  • Some wonderful thoughts in this post, Gerry.

    You pose the question about coping with loss as a doctor in a rural community, but I think you’ve probably answered your own question. Sometimes by being more connected, and having the ability to comprehend the family’s grief on a deeper level, I find it more possible to deal with my own grief in these situations. I think it’s important to acknowledge that we will feel loss in our own way as doctors when our patients die, just as a patient’s friends and family will.

    The chance to be able to guide dying patients, managing not only their symptoms like pain, but also their fears and uncertainties, is one of the most meaningful aspects of being a doctor. I wouldn’t give it up for anything.

    June 02, 2013
  • This is a timely post for me, as I’m planning to write my next blog post about GPs becoming friends with their patients. There is a wealth of literature about the dangers of being a doctor to your friends, but almost nothing about the fact that we do become friends with our patients. How we define ‘friends’ or discriminate between being ‘friendly’ and being ‘friends’ is a part of my interest, but I am particularly concerned that we are falling prey to the political drive to promote a transactional / consumer model of healthcare that ignores the deep therapeutic relationships, that we are in danger of becoming the cold, objective brokers of medicine, rather than long-term, committed partners in care. There are several good papers about doctors and patients being friends that may be of use at the end of my blog about loneliness: http://abetternhs.wordpress.com/2013/05/04/loneliness/
    The piece that inspired my thoughts about being a friends to patients and living in a community (that I am sure you will enjoy) is this one by Julian Tudor Hart: http://www.bevanfoundation.org/wordpress-content/uploads/2011/10/Platfform+2+JTH.pdf

    “I learned that for GPs who lived within a community and made friends with their patients, management of illness was usually much easier”

    June 02, 2013

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