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Holland M. Kaplan ~

I'm sitting in the ICU team room, staring at the computer, trying to look like I'm writing a note. But my head is pounding.

As an internal-medicine resident doing my first month of residency, I've found the ICU of the bustling county hospital a jarring place to start my training. Although I'd anticipated the clinical challenge of caring for very ill ICU patients, I was unprepared for the emotional burden of having to deliver devastating, life-altering news to them and to their family members.

Faint yells emerge from Room 7. They have an almost rhythmic quality: "Ahhh!"…(three seconds)…"Ahhh!"…(three seconds)…"Ahhh!"

It's Ms. Burton. I've just gotten back from checking on her, but I plod back again.

"Ms. Burton, are you in pain?" I ask loudly. She stops yelling and glances at me.

"No," she says, her voice high-pitched and childlike.

Per her chart, Ms. Burton has suffered some kind of injury that caused her brain to be deprived of oxygen; no further details are known. Her face and arms are heavily bruised, and we're worried that she's being abused at home.

Hoping to ease her suffering, I try several different ways to ask what's bothering her. Each time she replies, "I'm fine." Eventually she turns away, a blank stare on her face, and starts yelling again.

Forlornly, I gaze at her, then quietly say, "I'm so sorry." I sigh, feeling disappointed in myself, and walk back to the team room.

The phone rings, and I answer it.

"Hi, Doctor, this is George calling about Mr. Smith in Room 15. His brother is here."

My eyes glaze over as I anticipate my upcoming conversation with this patient's brother--the conversation I've already had with three of his other family members.

"Thanks, George, I'll be right over." As I head for the door, the phone rings again. I pick it up.

"ICU," I say wearily.

Quickly, a nurse speaks: "Ms. Lifton's husband is going to be here shortly and asked to speak with a doctor."

"I'll be there soon, thanks." I walk to Mr. Smith's room.

Mr. Smith's brother stands by the bed, clearly in shock at the sight of his brother, who's intubated and has a second tube draining blood from his head into a plastic bag.

"Hi, I'm one of the doctors taking care of your brother," I murmur. "Let's talk in the family room." I lead him across the hall. We sit down.

"What has your family told you about what happened?" I ask as gently as I can.

"Nothing," he says woodenly. "I got the call last night that Billy was in the hospital, so I came this morning as soon as I could." I gaze at him, knowing that what I'm about to tell him will change the rest of his life.

"I wish that I had better news, but unfortunately your brother is in a coma." I pause. His eyes slowly well up with tears.

"I'm so sorry," I say, handing him a tissue and putting my hand on his shoulder. His body quakes with heavy, silent sobs.

"What happened?" he finally croaks in a broken voice, looking up at me. Briefly, I explain how his brother's high blood pressure caused him to have a stroke.

As he continues to weep silently, I say, "You're welcome to spend some time in this room, if you'd like. Please let the nurse know if there's anything I can help you with." He nods, reaching for another tissue.

I close the door and stand in the hallway, rubbing my eyes. I feel so helpless. I want nothing more than to tell my patient's brother that his loved one will recover. But the window of opportunity during which I could have made a difference to Mr. Smith's health closed long before I ever saw him.

What can I actually do for Mr. Smith's family? I wonder. Have I at least done a passable job of compassionately telling this man that his brother will never walk, talk or be the same again? Fleetingly, I realize that probably the most meaningful thing I can do for them is to communicate the medical situation patiently and clearly, lend a listening ear and offer my sympathies.

I sigh and head down the hall to see Ms. Lifton, who was brought here after suffering a cardiac arrest. On the way, I pass Ms. Burton's room ("Ahhh!…Ahhh!…Ahhh!").

As I walk in, I see that Ms. Lifton has been extubated and is waking up. Flailing about, she makes incomprehensible noises through contorted lips and tries to tear out her IVs. A nurse grabs her hands and calls her name, trying to get her attention.

I go and stand at her bedside, reflecting sadly that this might be Ms. Lifton's new normal. Then I turn and see her husband standing in the doorway. He stares wide-eyed at this woman who's been his capable life partner up to this point, but whose physical abilities now resemble those of a young child.

Slowly, he approaches her and reaches down to cradle her face. She tries to bite his hand. He recoils, and a tear falls from his face onto the sterile white bedsheets. He starts sobbing.

"She's acting like she's disabled," he says to me hopelessly, desperately, pleadingly--clearly wishing that this were some horrible nightmare from which he could awaken.

"I'm so sorry," I reply, trying to hold back my tears.

This must be one of the worst days of this man's life, I think. Eventually, unsure what else to say, I retreat to the team room.

Sitting down, I give up any pretense of appearing busy. I rest my forehead on my hands, trying not to sob out loud. My mind and body throb with heart-wrenching thoughts and feelings: It's so emotionally trying to constantly witness the worst moments in people's lives...to be the one who's delivering the bad news that changes someone's life forever...to be unable to help someone who's clearly suffering.

Caring for irreversibly ill patients like Ms. Burton, Mr. Smith and Mrs. Lifton feels like walking in at the very end of a long, complex movie. I want to make a difference in their lives and health, but their stories have already unfolded.

The sad truth, I'm reluctantly learning, is that sometimes the most I can offer is to be present with people, to listen to their sadness and pain--and to express my own by saying, "I'm so sorry."


About the author:

Holland M. Kaplan is a first-year internal-medicine resident at Baylor College of Medicine in Houston. Her interests include medical ethics, end-of-life care and heart-failure management. She hopes to specialize in cardiology and medical ethics, and eventually to work with end-stage heart-failure patients. "I've always enjoyed writing. As a philosophy major in college, I did a lot of academic writing. Since medical school, I've been writing about interactions with patients as a way to process my experiences. Writing this piece helped me manage my feelings of being overwhelmed and emotionally exhausted during my first month of internship."

Story editor:

Diane Guernsey

Comments   

# Eston 2018-03-02 10:12
Thank you for your experience. One of my biggest fears is not being able to hold it together in situations like you described. I am on my nascent journey towards becoming a doctor in my mid 40s. After having lost my young sister to cancer, I am an altered person, sensitive to the sufferings of others. Hypersensitive at times. How did you adjust to these experiences? Did it get easier? I hope it did.
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# Rhonda French 2018-02-24 18:28
Holland, I'm so proud to be your friend.
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# Pringl 2018-02-24 14:57
Dear Dr. Kaplan - Thanks for writing and sharing!

You wrote - you don't think you did anything for these patients and their families. I disagree. The inciting events happened before you were involved. You can only effect what happens during your watch. The ICU experience these patients and their loved ones have is "critical" to their grieving process.

As medical professionals it's unreasonable to think we can always effect a positive change and be the 'hero". What did Hippocrates say? "To cure sometimes, treat often, and comfort always".

You had a tremendous privilege, whether you felt it or not, to be that compassionate and supportive doctor who delivered bad news during an intense time of pain and suffering. They will likely remember you, long after leaving the ICU.

Being present with them in the moment at an unwelcome time is the most meaningful therapeutic intervention you can offer.

Well done!
Pringl Miller, MD, FACS
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# Kristin AW 2018-02-24 12:18
Listening, being present and offering empathy is everything. As someone with a chronic medical condition, I have learned that a doctor who does the above makes all the difference. I have thought a lot about how exhausting it must be for doctors to "show up" as a human being with empathy to each of your patients and their individual stories—especia lly when "fixing" them is elusive. It is a beautiful (and sadly, a rare) experience to feel that the person guiding you through treatment is invested in your well-being. It makes a profound difference in the lives of patients and families. And I am beyond grateful when it happens!
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# GS Ford MSN RN FCN 2018-02-24 10:06
Bless your heart! You are learning the hardest lesson of patient care at the very beginning of your career and you're doing exactly what you need to do for these family members--being present and empathic. This is the greatest gift we give our patients. Your tears are cathartic for you and are a witness to your depth of caring for your patients. I pray that you will always have the strength to remember and be present and empathic to your patients/famili es.
I told my nursing students and fellow staff that patients don't care how much you know until they know how much you care.
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# Neddie Ann Underwood 2018-02-23 23:17
Holland--you are such a stunning author and person. Keep sharing these stories; your voice is such a beautiful addition to the discourse of how we strive to care for others even when it is painful and difficult and complex.
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# Laurin Bellg, MD 2018-02-23 21:25
Dear Dr. Kaplan,
Please keep writing - it is beautiful prose - and perhaps consider critical care as a specialty. I've been practicing in critical care for nearly two decades and recognize the scenes you describe so eloquently. It does get easier and strangely over time it morphs into an area where you feel you are inhabiting sacred space to be able to be with family members as they are grappling with the new reality of their loved one. What you describe so beautifully, I recognize and feel I see it every day. You have a gift for documenting these vivid scenes, so I encourage you to continue. I have also written about the critical care experience myself, so if you feel inclined to reach out, please do. Sincerely, Laurin Bellg, MD (Critical Care Specialist, Wisconsin)
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# Pris Campbell 2018-02-23 20:35
So painful to live through these traumas with family and patients. I know you’ll be a good doctor. You don’t try to stuff your feelings for yoir patients away.
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# Virginia Seno 2018-02-23 20:11
Their story has not unfolded as they're still living and living-with awful things happening. Presence *is* all that can be, and strangely enough, it's everything. Nothing more is needed. You're doing wonderful work and making a difference that you can't even tell. Maybe someone's grief will be less complicated because you helped the way you do. I'm guessing so as I've been that young widow with few clinicians who could even speak or make eye contact. You go. Keep helping that way.
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# Susan Boyko 2018-02-23 19:44
Thank you for sharing your story with us. You have learned so much already about being present. Keep writing and sharing.
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# Nancy Curran 2018-02-23 19:21
You are going to be a wonderful doctor. Learning how to walk along beside someone when you can't change the outcome takes time. So many people feel isolated as many people will avoid them because they do not know what to say. It isn't words that they need ; people need people. To hold space; touch the arm, hold their hand, let them know that you care, share a tear...... you have already learned that. Keep holding space; keep loving them. Blessings to you.
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