Last month I was on the hematology service at the University Hospital. It is a service primarily composed of patients with leukemias, lymphomas, or a disease called multiple myeloma (a rather unique cancer of the blood). Very busy service, routinely with 18-20 patients to see each day and manage outside of new admissions and coordination of discharges. It's easy to let yourself get automated in such an environment: are the labs normal? Ok. Any fevers? Yes? Draw blood cultures and start antibiotics, lets move to the next patient.
Medicine is perhaps easiest when you know the problem and know the solution, and you see that the solution works. A great example would be a patient with an ear infection; I simply prescribe antibiotics in the clinic and they go home, 5 days later their ear is better. Medicine is far more difficult when death comes into play, or you have a therapy that doesn't work. Such is life on a cancer ward.
I have seen a number of my or my colleages' patients die. Often though the patient is either too incoherent thanks to numerous narcotics and sedatives to know, or too young to comprehend. In those cases death is discussed with family.
On a cancer ward, you have the opportunity to diagnose someone with something that will take their life, but it may not be today that they die. It may not even be this month. The patient may not even look sick, but instead of telling the family that this loved one will die of their disease you will have to tell the patient. You have to tell them knowing that they will have to come to grips with their own mortality and it may sadden them or scare them, and you will know that you brought this news. This I have found is the most challenging thing I have faced in medicine.
Death tends to be a difficult thing for physicians, even though we are far closer to it than the general public ever is. Perhaps it is because of what death is, that somehow it represents a failure. We are called to bring health to the sick, and are known for bringing people back from the brink of death. We, as a group, have a hard time acknowledging that no matter what other disease statistics exist that 1 out of every 1 patient of ours will die eventually. Of course that's not entirely true (we do know that people die), we simply hope it doesn't have to happen on our watch.
On the hematology service, many people were sent home on hospice. The mood for these kinds of discharges is very somber. There is a lot of sadness. There is a lot of fear you can feel from the patient and family. There's the sliver of hope that somehow a miracle will occur and the patient won't die, and it's not always the patient or their family who entertain such hopeful thinking either. "See you later," somehow seems offensive, "Goodbye," almost a sentence. Somehow though people who were dying or went onto hospice were glad to know the true prognosis of their condition, and many when they know and could feel the reality of their fate desired more than all to go home, spend whatever time left with family and in comfortable surroundings.
I am moved on now to a new rotation and see far less terminal illness (at least, far less patients so near to death) and it feels easier. I am sorry though that I maybe am not as comfortable with death as I thought, at the very least not speaking of a patient's future death as a near and real thing. This hopefully will change in time. I hope I do not get numb to the mortality of patients, but I hope I do not fear their passing so much that I hide the reality of it from them lest they have no chance to prepare.
