“Death is the opposite of life, but a part of it.” – Haruki Murakami

I’ve never given much thought to death, but working in a clinical setting and coming into contact with dying patients and the idea of death itself, forced my thoughts in that direction regardless. Death is defined as the permanent cessation of all vital functions (Merriam-webster.com, 2019). Death is the end to life and it is unavoidable and inevitable. There are different opinions and viewpoints regarding death – some religions view death as a positive transition to the afterlife or a different realm of existence, whilst others view it negatively and associate death with pain and an unchangeable finality.

As healthcare professionals, dealing with death and dying patients is inescapable and is bound to happen. I would normally say unfortunately so, but perhaps it could be fortunately, as we are placed in situations which force us to grow and deal with the inevitable course of nature. Thiemann et al. (2015) states that medical professionals and students are exposed to death more so than other members of society – which is understandable seeing that we work in critical care environments. This is not necessarily a good thing, as more frequent contacts and dealings with death can lead to the development of death anxiety, which is defined as “an unpleasant emotion of multidimensional concerns that is of existential origin, provoked on contemplation of death of self or others.” (Thiemann et al., 2015). Even knowing that death is a predestined and natural part of life, the occurrence of it can still bring you to a halt and leave you in shock. That was the position I found myself in, during my ICU block.

In the beginning of the year, my first block was in a Medical ICU. I was aware that this was a critical clinical setting and I expected to be exposed to more serious situations during the block. During the first 3 weeks of block, a few of my patients passed away. I was informed of all of these patients during the morning discussions with my clinician. This was very similar compared to what I had experienced in third year – I was informed that the patients had passed away, but often it was over a weekend or during the night, so I was never truly involved in the whole process. The thought of it never really bothered me as much as I would have expected it to, because with all these cases I was able to carry on with my day as if nothing had changed, but things were different on one specific day in the ICU. One morning before ward rounds I went to see a patient who I had been seeing for 3 days. Upon arrival at the patient I could see his vitals were unstable and in the file it was noted that the patient’s condition had deteriorated. He was on a high dose of Adrenalin, which I then queried with a nurse, who informed me that things were not looking good for him. Treatment was definitely contra-indicated, so I left the patient to join the doctors on ward rounds. During the rounds we eventually ended up back in the room where this patient was lying. He was the first patient to attend to in the room, but the doctors skipped his bed for the round, which I thought was strange, but I followed accordingly. We then discussed the patient in the bed next to my patient. I was standing behind the doctors, still very close to my patient with my back facing him, when I heard the sound – a monotone coming from the vitals monitor situated above my patient’s bed.

In that moment, looking around the room, I noticed I was the closest person to my patient at that moment and that is when it truly hit me. I stood still and in shock as the nurses and doctors moved around me and continued their normal activities. One nurse moved towards the patient and switched off the monitor and the doctors just looked up and continued with their discussion of the other patient. I was hit with so much emotion – why were they not bothered by this? How did it happen so fast? Was anybody going to do something about this? Then again, what could they really do – he was a DNR patient.

I was taken aback by the nonchalant attitude displayed by the doctors and the nurses and in that moment I could not justify their behavior – although ironically I was not doing anything much about it myself. I think in my head I pictured the scenario to play out differently, when in fact this was what dealing with death as a health professional was really like. During a previous study, it was found that physiotherapy students reported a contrast in reactions to death in health-care settings (Powell & Toms, 2014). Many students felt as though other health professionals were being insensitive and lacked emotion due to their continuation of normal activities and lack of emotion shown when patient deaths occurred (Powell & Toms, 2014). Students also often feel as though these staff members are unable to empathize with their reactions, leaving them unsure as how to cope with their emotions. I found a YouTube video very interesting where a doctor spoke about his personals experiences with death and dealing with it. In the video he said: “we don’t even have time to think about a patient who just died, because we have to get back to work and it shouldn’t be that way…” which was a thought provoking statement for me.

In that moment I also felt so terrible that I had unknowingly been the person closest to him, but still he died alone in a cold sterile room. I knew he was unconscious at the time, but the fact that he had no one with him and that no one looked as if they cared enough to attend to him immediately at the sound of the flat lining monitor, left me saddened and angered at the same time. This was the first time I truly faced the reality of death and I did not know how to deal with it. According to Powell & Toms (2014), discussing the events with peers, using online forums, reflective writing and formal counseling were identified by physiotherapy students as effective methods to cope with the death of a patient in clinical practice. It is important that we as health care professionals deal with our emotions regarding death and identify effective coping mechanisms to overcome the negative impact of death in our lives and to prevent death anxiety. In a previous study done it was found that students in the medical professional have higher incidences of psychological distress compared to other students, which was linked to their frequent exposure to death and dying (Thiemann et al., 2015). This has also been linked to resulting poor quality of care provided by these students (Thiemann et al., 2015).

As I mentioned earlier, I’ve never really thought about death and everything surrounding it, but experiencing this situation with the death of a person right next to me, the whole scenario and this new perception of death actually instilled some fear in me. There are various kinds of fear regarding death – premature death, the process of dying and being dead. My fear was not of death itself, as I am religious and believe that there is life after death and life in abundance for John 11 verse 25-26 says: “I am the resurrection and the life; he who believes in Me will live even if he dies, and everyone who lives and believes in Me will never die.” I know of the eternal life that starts after death, so this was not what bothered me, it was the process of dying which I developed a fear for. Howells & Field (1982), found that medical students had a significant greater fear of death compared to non-medical students and it was found that these students had a greater fear for the process of dying than actually being dead – the thought of non-existence. As humans we are wired to survive, to be self-sufficient and to work towards self-preservation, so the idea of an uncontrollable end to an ongoing survival is quite scary to me. The process of dying alone with no family or friends or even a familiar face around you is not a death I would wish anyone in the world. In the Japanese language they have a word for this phenomenon: “kodokushi”, which means “lonely death”. The thought of it scares me, and I believe perhaps others as well, and I had to learn how to cope with this reality. Dying alone is seen as a ‘bad’ death according to society, media portrayal and cultural beliefs (Seale, 2004) Even though the definition of a good and bad death might not be available, I think we all want a “good death” at the end of the day. In the United Kingdom there are policies that promote the idea of choice for dying adults, as they believe that, if these adults have the right to exercise their own choices regarding all aspects of their healthcare it will in turn result in a good death (Department of Health, 2008; Choice in End of Life Care Programme Board, 2015).

This whole experience regarding death was quite complex for me. Not only did I have to accept how other health professionals deal with death, I also had to find my own coping mechanism for dealing with death as well as overcome a new unknown fear for the process of dying. This was the reason I decided to write about death as a whole and not focus on one specific aspect, as I found the whole concept of it complex and integrated and I believe each part of it is an important part to be discussed.

After quite some time pondering the thoughts I found that I actually now accept the process of death more and could find a way to overcome my fear. It is natural process which should be respected and helping people during their last hours should actually be seen as a privilege. Through this process I was also able to identify different coping strategies for dealing with deaths, which I could use in clinical practice. It was also important for me to see the doctors and nurses reactions to death, as I now understand and respect that everybody deals with it differently.

I am thankful that I was in that room when it happened that day and that I experienced it the way I did, as it forced me to do some introspection and deal with the reality of death and develop my own thoughts and opinion of it. This to me was important, as it will equip me to better deal with terminally ill patients appropriately in future.

References:

Department of Health (2008) End of Life Care Strategy. London: Department of Health.

Howells, K & Field, D. (1982). Fear of death and dying among medical students. Social Science and Medicine, 16(15), 1421-1424.

Merriam-webstercom. (2019). Merriam-webstercom. Retrieved 20 May, 2019, from https://www.merriam-webster.com/dictionary/death

Thiemann et al. (2015). Medical Students’ Death Anxiety: Severity and Association With Psychological Health and Attitudes Toward Palliative Care. Journal of Pain and Symptom Management, 50(3), 335-342.

Powell, S & Toms, J. (2014). Passing Away: An Exploratory Study into Physiotherapy Students’ Experiences of Patient Death whilst on Clinical Placement. International Journal of Practice-based Learning in Health and Social Care, 2(1), 108-121.

Seale, C. (2004). Media constructions of dying alone: a form of ‘bad death’. Social Science & Medicine, 58(5), 967-974.