A patient of mine died unexpectedly this week. He had colorectal cancer.
I only met this man three times. Still, his death has impacted me.
Our first meeting was for his initial consultation to discuss chemotherapy to cure his cancer. I recommended six cycles of chemotherapy. His chemotherapy was to start shortly after the radiation treatment that was also recommended in his case.
His chemotherapy had two components: an intravenous drug given once every three weeks and pills to be taken twice a day for fourteen straight days. After these two weeks of pills, he had a week off to recuperate. Each of these three-week blocks (on chemo for two weeks followed by one week break) is called one cycle of chemotherapy. As per usual, when he and I met the first time, I went over chemotherapy, how it works, why it was being recommended, and the side effects that might occur. He consented to this treatment. He then had to attend a nurse-run chemotherapy teaching class where the side effects were reviewed again and other information about diet and exercise were explained. He received appropriate phone numbers to call should he run into difficulties.
I met him a second time right before he started his first cycle of chemotherapy. We reviewed the chemotherapy information again and I confirmed he was ready to start his treatment.
Our third meeting was three weeks later, prior to his second cycle of chemotherapy. He reported that he had generally done well with the first cycle of chemotherapy. His blood work was adequate at that time. There were no major adjustments required to his treatment. We decided to proceed with cycle two.
Three weeks later, on the day he was to return to see me for his visit prior to his third cycle of chemo, I found out he had died a few days earlier.
According to our electronic health records systems, he had presented to one of the local emergency rooms with severe abdominal pain and was found to have a bowel perforation. A bowel perforation means he developed a hole somewhere along his intestines. Perforations are bad. They should not occur unless there is something sinister happening. In this man’s case, a perforation caused a buildup of air inside his belly cavity and an infection rapidly developed.
This man’s hospital discharge summary states a general surgeon saw him to discuss the option of undergoing emergency surgery to potentially fix the perforation. I am not privy to the discussions that were had between this man and the surgeon that consulted on his case. I do not know what was said to him or how he reacted to this information. I am not sure what statistics for surgical success and failure were given, if any. Surgery certainly would have been very high risk and fixing his perforation would have been a long shot. Surgery was not pursued. He died a short time later.
This man’s cause of death was severe infection secondary to bowel perforation. But why did his colon perforate? There are several possible considerations. His perforation could have been due to his cancer. It could have been due to complications from treatment. It could have been due to complications from non-cancerous causes including diverticular disease or a blood clot that blocked off blood supply to his bowel thereby making it weak and more susceptible to perforating. It could have been something else altogether. To my knowledge, an autopsy was not ordered. Without an autopsy, the location of his perforation will not be known, thus the exact cause of his death will never be certain.
I extend my sincerest condolences to the friends and family of this man for the loss of their loved one.
The death of this man has been on my mind all week. I think about death a lot. I think about how death affects the people that know the person that died. I think about the influence of death on the members of our health care team. I think about how a patients’ death impacts me.
I do not write this flippantly in any way. I want to be very clear that I recognize the death of a patient is not the same as the death of a loved one. I feel so heavily for the families of the patients I take care of during and after a cancer death. Yet when a patient dies, it does have an impact on me. I imagine the same is true for my physician colleagues and many of the other members of our cancer care teams. I wanted to write about this patient and his death to highlight the importance of health care worker and physician wellness when the death of a patient occurs.
I have patients die all the time. Experiencing death is part my job. Knowing many of the patients I serve will die as a result of their disease is hard. I knew this was going to be the case when I decided I wanted to be a medical oncologist. I didn’t know, however, how much it would affect me.
Sometimes death occurs while I am still actively involved in a patient’s journey. More often death occurs after I have discharged a patient from my care because I have nothing left to offer them and they are better served at that point by our palliative care teams. This man’s death was unique in that I was involved in his care for the purposes of curing his cancer. Without a perforation, he might have finished his chemotherapy, he might have then gone on to surgery to have his cancer cut out, he might have recovered never to have his cancer recur, he might have lived a normal life span, he might have done alright for a while without radiologic evidence of his cancer but one or two years down the road his cancer might have grown and killed him then, he might have died from a different medical condition in a year, he might have been in a car accident and died two weeks from now. He might, he might, he might . . . no one will ever know what might have been.
I think health care workers need to be able to talk about patient deaths. I think we need to say out loud how we are feeling when death is front of mind and heavy in our hearts, to voice these feelings not so someone else can hear our feelings, but so that we can hear our feelings said out loud in our own voice. I believe if we do not, or if we feel we cannot, our job can become too difficult. We can’t carry grief for the deaths of thousands of patients we will care for over the years of our careers. If we did, we would surely burnout and then be of no service to anyone.
It is probably true that the extent to which a death impacts a health care worker is dependent on many factors: position in the health care team, intimacy of the experiences with that person, length of time within the therapeutic relationship, conditions around the death, expected versus unexpected timing of death, the patient’s and caregiver’s own life circumstance, age of the patient and caregiver, the role one had in the patient’s cancer journey . . . the list can go on and on.
I shared my feelings about this patient loss out loud with my best friend early in the week. In the moments of sadness and frustration about the losses I experience during my working hours, I often land on the sentiment “there is so much failure in my job”. This week when that happened, my person raised so many pertinent questions in response to my remark. She asked: What is failure? What is success? What does that even mean in my job? How is it measured? Who decides?
Oh my goodness – all of these questions are without answers. And for me, the question of “who decides?” had me going in the direction of “please let it NOT be me”.
From these questions, the definition of failure has been nagging at me and bouncing around in my head. Is death failure? Death of a patient can often feel like failure to me. Failure is the last thing a doctor wants to feel. We are trained to perfect perfection after all. But we are human, and humans die. Even with our best efforts, people die. In the oncology world, a lot of people die. This can leave feelings of guilt, inadequacy, sadness, frustration, and at worst, failure.
My best friend reminded me that the truth of the matter is that often the odds are not in favour of long-term survival for the patients I serve. It continues to sting when patients do not do as well as the average data would suggest. But death is part of life. Death, in fact, is one of the only certainties of life. This is a paradox that neither magic nor mystics can tamper with.
Author Notes:
The conversations I had with my best friend this week about perceived failures at work morphed into a more generalized discussion about the definition of failure. Failure is such a subjective word. The word success is the same. While I pondered these words and their meaning this week, I realized everyone could have their own measuring sticks for these words. We so often fall short of understanding what we each mean when we think or speak these words to another person. I will try to have more intention moving forward to bridge such chasms of misunderstanding. I think defining what one believes to be failure versus success must be the foundation for any important dialogue on these topics.
With permission from her to use her words, I will end this blog post by sharing some best friend wisdom on failure:
“I think it is really important to experience failure – lots of it! And the earlier, the better! Fail. Try again. Fail. Try again. Get up and keep going, each time armed with new information that we have acquired from these experiences. Get back up, re-group, big breath in, chin up, chest out, big smile, and off we go again! Be bold and daring. Be hopeful. Be open-minded. Be willing. Be humble and kind. Summon the faith to believe we can do what we set out to do . . . to do better and be better, despite our shortcomings and our fears. Learn to trust ourselves . . . our true selves. Never stop growing. Never stop learning. Keep reaching for the stars.”
Perhaps this is the most beautiful way to think of failure – as a stepping stone to success.
I’d like to thank my daughter for her help with the Venn diagram. 😊
I’d also like to ask what is “failure” to you and what has your biggest “failure” turned into success? I am curious to know.
