Nothing to Hide
About thirty years ago, after I'd completed my internal medicine residency and a rheumatology fellowship, my wife and I moved with our three-year-old son to my wife's hometown.
There I joined a multispecialty group practice as the second rheumatologist. Over time, the plan was for me to build a rheumatology practice, but while that was happening I took on all kinds of patients, both primary-care and intensive-care. I felt very comfortable doing general internal medicine, and I also liked the intensity of ICU work. Handling the technology of medicine--ventilators, Swan-Ganz catheters, dialysis---made me feel knowledgeable and skilled. My older partners were glad to let me handle the ICU patients. I felt needed, and I liked it.
A few years passed; we added a second son and became more and more a part of the community.
One weekend, while covering for my partners, I went to the ER to admit a young man who needed to go to the ICU for apparent liver failure. The patient, Nate, a burly, round-faced man in his early thirties, was mentally confused (a side effect of advanced liver disease), so I got most of the story from his wife, a slender, soft-spoken, pleasant-looking woman named Julie.
She told me that Nate was a mechanic. He and Julie had two little girls, who were there with her. The girls were a bit younger than my boys, and a lot better behaved. Though clearly not total strangers to the hospital setting, they seemed to understand that something was different this time around; they kept quiet and stood so close to their mom that they looked like appendages.
While the ICU staff kept the girls occupied, Julie and I talked about Nate's prognosis. His liver disease did not seem to be caused by any of the usual suspects--drugs, alcohol, travel, sexual activity or a transfusion. In fact, his history had been pretty unremarkable until recently.
I wish I had a medical student here with me, I thought. I love to teach, and this would be a great opportunity to see so many of the findings characteristic of liver failure--the jaundice, the curious, spidery blood vessels on the skin, the redness of the palms, the fluid in the abdomen. And in the best-case scenario, if our treatment helped, Nate's confusion would gradually clear.
I started Nate on the standard treatment regimen, but his mental status never improved to the point that I could get to know him--to find out about the things that gave meaning to his life. Instead, I saved those questions for my rounds, when I knew Julie would be there. From her I learned that Nate's wants were pretty simple: watching his girls grow up to be like their mom, going fishing and getting the mortgage paid.
Nate's medical course over the next few days was predictably stormy, complete with internal bleeding, ventilation, pressors (medications to maintain his blood pressure) and consultations with other specialists. As he slid inexorably downhill, I felt myself wishing more and more that he would recover--at least enough to talk with his kids, to smile at his wife.
I threw every bit of knowledge and technical skill I possessed into his care: I virtually camped out in the ICU, monitored his status and bugged the nurses about his blood gases, ventilator settings and coagulation status. But despite all my efforts, the end kept coming closer and closer.
Along the way, I talked with Julie about Nate's potential demise, and she was as well prepared as any young person can be for the death of a spouse.
Only a few days after he'd been admitted to the ICU, Nate died. The nurses called me in the clinic to let me know that his heart had arrested, and I immediately drove to the hospital, arriving in time to be the one to end the code.
Thankfully, the girls were at home with their grandmother. Julie had left the hospital briefly, but was due back soon.
During medical school and residency training, I'd had more opportunities to deliver bad news than I'd ever wanted--enough, you'd think, to have mastered the basics. But, in contrast to many of medicine's technical skills, telling someone of a loved one's death never gets easier.
Shortly after Julie returned to the hospital, I met her in the hallway.
After one look at my face, she seemed to know.
"I'm so sorry," I told her.
My voice cracked; sadness welled up and choked me. Even though Nate's death was entirely expected, and she had been prepared, I felt profoundly saddened. It wasn't just sympathy I felt at that moment. I so identified with Julie: I felt her pain as my own.
What Julie did next took me by surprise--but it also comforted me.
She took my hand.
"I'm glad that you couldn't hide your feelings," she said. "That shows me that you really cared about Nate. He really meant something to you, even though you weren't his regular doctor."
We hugged. Then I led her to Nate's room, where he lay minus all of his wires and tubes, looking more like the man she'd married and less like an ICU patient.
As the nurses kindly took charge of the formalities involved in an ICU death, I found a stall in a little-used bathroom and cried.
I dictated my final note, lingered a while longer to see if there was anything I could do for Julie and finally drove home to my family.
Today, whenever I talk with students about delivering bad news, I always remember Nate and Julie. We all know that giving bad news is difficult, and we believe that hearing bad news is even more difficult.
Julie's reaction, however, taught me that showing genuine emotion, "wearing my heart on my sleeve," can have a powerful healing effect--and that, even in the most painful moments, many patients offer healing in return.
About the author:
Kevin Dorsey has been the dean and provost of the Southern Illinois University School of Medicine for the past eleven years. "For many years I have led students in all four years in a series of discussions which I call Empathy 101. These sessions are triggered by readings that in some way relate to the sacred space between patient and doctor. In the course of these discussions, I have often told the story related above, as it felt so compelling to me, but I never before had the courage to write it out. This is the first nonscientific writing I have ever done."