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.