Saying the D-Word

It was late in the evening, and I was ready to start my night shift as an intern in the intensive-care unit. I sought out my fellow intern, who was finishing his shift, so that we could perform signout–the ritual of passing the patients’ information from one clinician to the next.
“Mrs. Klein in Bed 15 might go,” he whispered.
“Go? Go where?” I asked. “It’s 10 o’clock at night.”
“I mean she might go away.” He wasn’t making eye contact with me.

“Where?”
“Forever.”
My look of confusion remained. Also, why was he whispering?
“She’s comfort measures only.”
Only then did I understand: He was telling me that Mrs. Klein might die. Before I could say or do anything to indicate that I understood, he moved onto the next patient. His voice resumed its normal volume as he talked about gastrointestinal bleeds and small-bowel obstructions.
As physicians, we discuss intimate topics with our patients. We talk with them about things that they discuss with no one else in their lives. We ask about sexual activity and drug use. We hear about affairs, and breaking the law. We talk about bowel movements and bladder control. We perform rectal exams and bowel disimpactions; we palpate scrotums and examine pelvises.
I’ve seen my colleagues ask these questions and complete these physical exams with assurance and poise. And I’ve seen how their confidence puts patients at ease, creating an atmosphere of trust that allows for meaningful caregiving.
Hours into my shift, one of the intensive-care nurses walked up to me. I was slumped over the computer, typing vigorously, as interns often are, and eating a packet of graham crackers meant for patients, as interns often do.
“Bed 15 expired,” she murmured.
Expired? I thought. What type of medical diagnosis causes that? Then I remembered that this was the patient I’d been told was “comfort measures only.” She had died–and, as the intern, it was my assumed responsibility to pronounce her dead.
This was the first time I’d pronounced a patient dead on my own. As I walked to Mrs. Klein’s room, the word expired kept rolling around in my mind. I couldn’t help thinking of food that’s past its “use by” date–and then of my grandmother, and her approach to such food.
I’ve seen her do it all: scratch off expiration labels, transfer expired food to unlabeled containers, retrieve food that we’d dared to throw out, then return it to her fridge. I thought about all the bouts of food poisoning I’ve suffered after agreeing to stay for dinner. I thought about how she holds on to my grandfather’s medications, even though he died years ago.
“What if I’m prescribed a similar medication?” she insists. “No point buying what you already have.”
My stomach started to churn.
But then I saw Mrs. Klein, with her perfectly painted toenails, dented wedding band and well-earned wrinkles. She was not a number, a bed, a smelly refrigerator or a cluttered pill cabinet. Mrs. Klein was a spouse, a mother and a friend.
I called Mr. Klein.
“Your wife has died,” I told him as gently as I could. “I believe she died comfortably.”
On the other end of the line, I heard his tears. I asked him to share a memory of her that I could keep with me, instead of just remembering her as the patient who’d expired.
“We fell in love at the age of eighty, at a senior center,” he told me. “She was a widow of fifty years. I had never married. She was an amazing wife.”
As clinicians, we frequently bear witness to death. I am the only one of my friends, and almost the only one in my family, to have seen a person die. Like many of my peers, I find it hard to experience this, and even harder to put the news into words for the loved ones left behind–especially if I’ve never met them.
But I know that, as a physician, it’s my responsibility to help guide patients and their families through this inevitable part of the life cycle. As I grow more comfortable in that role and overcome my reluctance to explore end-of-life questions with patients and their families, I hope that I’ll be able to remind myself and others that it is completely normal to discuss and think about death.
Physicians can make this process easier, I believe, by simply revising our vocabulary. Only a few months into my intern year, I’d already heard so many euphemisms: “He didn’t make it,” “He bit the dust,” “He croaked,” “He’s going home in a box,” “He kicked the bucket,” “He’s not with us anymore,” “He passed.”
Rarely do we say, “She will die,” “She is dying” or “She has died.”
I’ve started to make sure I say the words “dying” and “death” with confidence and compassion–just as I would any other medical diagnosis. That way, I like to think, my patients will see my honesty and lack of fear and hopefully find comfort there.

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Charlotte Grinberg is a writer and a resident physician in internal medicine at Harvard’s Mount Auburn Hospital in Cambridge, MA. She has a particular interest in end-of-life care and will soon be working as an oncology hospitalist at Beth Israel Deaconess Medical Center in Boston. Her work has appeared in JAMAAnnals of Internal Medicine and Health Affairs, and she is the author of the French ethnographic book Nos enfants sont notre richesse: maternité et identité nationale en Guyane Française (Connaissances et Savoirs, 2015). She started narrative writing while majoring in medical anthropology and global health at Princeton University. “The practice of writing continues to help me understand the complex medical experiences of my patients and family members.”

Comments

10 thoughts on “Saying the D-Word”

  1. I get the family medicine and pall residents to watch Monty Pythons Dead Parrot sketch as a funny way to engage them about not using euphemisms , but to use the “dead” and “died ” words.

  2. Pris Campbell

    Thank you for this article. Yes, it’s time that we stop goose-stepping around the words dying and death.

  3. Susan D Greenberg

    In my first month as an administrative assistant in a healthcare facility the doctor who was my boss asked me to review a eulogy he had written. A beloved friend, mentor and colleague had committed suicide. The eulogy referred to “untimely demise” and “complicated circumstances.” With audacity and likely brazen insensitivity I edited the eulogy to read “gathered here to mourn the loss of..” “untimely death” and “beloved, respected, valued.” My boss took the edited copy silently, but thereafter constantly handed me notes to review; research publications being submitted to journals. personal notes to patient’s families. In my years in that role, I came to realize that those who choose a career in medicine wish to help, and are profoundly distressed when that is not possible.

  4. I, too, remember the first time I had to pronounce my first patient as an intern. It never occurred to me to ask the family member for a memory of the patient. I was too wrapped up in my own emotions. Thank you for your mindfulness and your compassion.

  5. Thank you for writing about your dedication to bringing the end-of-life conversation to your patients and their families. We were not told of our son’s impending death until he was receiving Palliative sedation. He had cancer, and there had been many opportunities to have this conversation in order to determine his preferences for end-of-life care. He was allowed to believe the immunotherapy was working because no one ever broached this subject at all. I will take the sorrow of that lost opportunity to the grave. Your outlook gives me hope for other patients in his circumstances.

  6. alice fornari

    thank you for writing this and sharing your humility and sensitivity to patient care at the most precious moment death-this is a gift to use educationally to have them bear witness to your words and ability to do it your way the right way vs follow bs role models

  7. This was so beautifully written. Such an important topic–I could never understand why doctors skirt the issue of death with their patients. Hopefully this piece helps change that.

  8. I was a hospice RN for 23 years. I didn’t use euphemisms for death and dying, but used the “D-word.”

    One of my funniest memories came while I was working on an Oncology unit in Dallas TX. The oncologist said that one of our patients was “going to Chicago.” I thought that was odd, as this patient was very ill. How would he get to Chicago? Why would anyone want to put him through such an ordeal? It turns out, that was one of the oncologist’s euphemisms for dying.

  9. I’ve long believed that by refusing to say the words dead, dying or death we give those mere words more power over us than it need have. Saying those words will not make things worse. They are facts of life. And to not admit that makes them infinitely more difficult to deal with.

    1. Dr. Grinberg, thank you for your commitment to this truth, because you use the word death with kindness, clarity, and compassion. I’ve been on the same path throughout my 30+ years in Family Medicine and Hospice care. This commitment is a gift to ourselves, our patients, and colleagues when accompanied by your kindness, rather than as a strident crusade. You’ve got it right.

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