“Time of death, 11:56 pm”

It was a Tuesday, my first Tuesday of night float actually. However, on that Tuesday I would forever be remembered as “Mrs. Smith’s last doctor” to her family. And on that Tuesday it will forever be the first time I had to pronounce the death of a patient, by myself, as a doctor.

Like I said, it was Tuesday. I just started night-float on Sunday night, so this was my 3rd night of night float. As this point I was ok at ‘handling things” overnight. I got the sign-out from one of my capable co-residents… “Mrs. Smith” is on hospice care and has end-stage lung cancer, she may go tonight. Oh. Ok.

No sooner did my co-resident take off to head home did I get the page from the nurse that Mrs. Smith’s whole family was here and wanted to speak to her doctor. I had received good signout about her case from my co-resident, but nonetheless I quickly went through her chart to know as many details as possible.  After I had collected myself, I walked into the room, ready to speak with her family…

I was prepared to talk to her children and maybe her grandchildren…

but I walked into a room with at least 20 people in it. Brothers, sisters, cousins, nieces, nephews, children, and grand-children. I introduced myself as the “Doctor taking care of Mrs. Smith” and each person in the room introduced themselves to me. Mrs. Smith lay in her bed with a non-re-breather on high O2. It was pretty clear to me and her family that her time was close. I spoke with the family a little about her care, and answered any and all questions/concerns they had. They were concerned that she was in distress and they wanted to make sure she wasn’t in pain. I got on the phone with hospice 3 times that night to consult about how best to manage her pain and titrate her morphine appropriately.

The last time I came to titrate the morphine she was laying comfortably and her family was relieved to see she wasn’t in pain. The tension of the room eased. Then I was paged out of the room because one of my other patients, Mr. Jones had positive troponins and I needed to contact my senior resident, upgrade Mr. Jones to the CCU, and call the cardiologist on call. A flurry of things happened trying to get Mr. Jones into the CCU and set up for a cath.

Then I got paged again. “Doctor, Mrs. Smith has passed, please come pronounce her.” As I hurried over to Mrs. Smith’s room, thoughts ran through my head. “What should I say after I do my assessment?” Should it be… “Sorry for your loss” or “My condolences” or …? I tried to remember what my senior resident(s) would say. I tried to remember what my resident when I was in medical school said. Which one was best? I’M NOT READY FOR THIS.

By the time I was in front of the door, I still didn’t know what to say.

As I entered the room, the whole family was in tears, all 20 of them. I made my assessment with all their eyes watching me and then I said:

“I’m so sorry for your loss.” and then I added, “I will give you all some privacy now. If anyone needs me I will be right outside at the nursing station.”

I walked out the door to the nursing station to sign the appropriate paperwork and do the last progress note. As I wrote my last note I kept beating myself up over and over again. What were you thinking? Why did you say it like that? What are you so sorry for? Of course they know you will be outside, why did you tell them that?

I felt stupid and I felt I had done it wrong. 

I started writing the last note, “Time of Death: 11:56 pm… ” Just then, a man walked up to me and I didn’t know his name, but he was one of the 20 people in the room…

He said, “Doc, Thanks for taking care of my sister. I know you didn’t know her too well, but we all know you tried your best to make her last moments as painless as possible. Thanks for that.”

When he said that to me, it all made sense. There wasn’t really a “wrong way” to tell someone their family member has died. Giving news (good or bad) depends on who is receiving it. I simply said what I thought was appropriate for the context of the situation. If that was my mom or my sister and my whole family was there, what would I want?

Over time, I developed my own way of breaking the news of death to families, but that first one served to remind me that:

Whatever I say will not change the fact that their loved one is no longer here.

1. Different people deal with grief differently. Some will want privacy and some will want questions and answers immediately. In my particular case, because the family was so large, I felt they might want some privacy to speak amongst themselves. This might be different if only one or a few family members were there. Over time, you will develop your own internal gauge of what the patient’s family probably wants.

2. However, I think being direct is always very important. The words “death” and “dead” seem morbid, but they are concrete. Try not to use euphemisms. In this particular case, I didn’t specifically state that Mrs. Smith had died… it was implied, but in hindsight, I really should have explicitly stated it and then offered my empathy and condolences.

3. Don’t rush things and make sure the family knows you are available if they have more questions. In this case, I didn’t rush them, but I thought they would probably want privacy and made it clear that I was immediately available to them.

4. Let them know what to expect next, such as the timing of death certificate and where to register the death. I didn’t do this until later.

TL;DR

“Time of death” is a right of passage for interns, and you will need to develop your own style which you are comfortable with.

There is no “right way”, but you can’t go wrong with just remembering what you would want if it was your own loved one.

See 1-4 above.

-Sensei

Agree? Disagree? Questions, Comments and Suggestions are welcome.

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