The Dying Season

by Tory Toles, MD

The Dying Season

Lives…loss of life, gift of life, many nights in one life.
Many nights in many lives.
You’ve taught me more.
I won’t forget.
That night. One night.
Many nights.

Winter, the dying season.

I heard a colleague refer to the winter months as the dying season and yes, as a resident covering the inpatient service at a local hospital during late November and December, that name seemed to encompass my time on the service well. It was overwhelming in its accuracy.

Performing clinical rotations in a small, rural town in Pennsylvania during medical school has made me no stranger to this terminology. But as a resident, with more responsibility, this phrase meant more to me than ever before.

On service, one ICU patient after another was dying. How could this be happening? What was I doing wrong? I felt sad, incompetent and beaten from my job. I was not sure how to cope.

I found myself recovering well during the workday, or so I thought, because I was required to maintain focus for the care of my other patients. But when my day off came around, I was suddenly and harshly thrust back into those events the minute I had the chance to relax. I was haunted by the faces of the patients I had lost and the voices of their distraught family members. I remember hearing one phone call I had with a patient’s daughter over and over any time I fell asleep, her distinct cries piercing and distinct even in a dream. Her cries brought back the faces of so many others- others from residency and others from medical school.

How do we cope with death as residents? We are overworked, over-stressed, and constantly doubting our decisions, choices, and expertise. We have limited time to process patient deaths and, I admit, in the moment my thoughts kept circling back to: this is my fault. I missed something. I made a mistake. This is because of me. Me. ME.

But this was never the case. The guilt creeps in so easily because we take this job to help patients, make them feel better and improve quality of life, relieve their fears, their family’s fears—make everything okay. But this is not always possible. Death is inevitable.

My experiences in medical school dealing with patient death ultimately drove me to pursue a career in family medicine so I could provide preventive care to reduce comorbidities for patients and hopefully, untimely deaths. They also helped me develop skills that made me more comfortable having end of life discussions with patient families while in residency. Despite all of this, the feelings of guilt and self-doubt surrounding patient death persisted.

This alludes to the importance of support and education surrounding managing patient death provided by residency programs and medical schools to address those unavoidable feelings and reduce burnout. Many articles also exist on how to deal with death and dying in medicine and how preparing students in medical school can help in the long term because this topic is so difficult for many. Ultimately, articles cannot prepare us for the emotional complexity associated with these events, but they do open up a dialogue that is also important on processing emotions. Ultimately, the experiences themselves prepare you.  

Below are some methods I have experienced in medical school and residency that have been effective for my own experiences:

  1. Support group: open dialogue about managing emotions, wellness strategies
  2. Debriefing after events: what happened, how it happened, what can be learned
  3. Co-resident reach out

It wasn’t until this winter inpatient rotation, during my intern year in residency, that I realized what I was doing wrong. I was not focusing on the exceptional care I was able to provide thanks to a wonderful team. Nor did I focus on the connections I was able to make with patients and their families. I kept making every situation about myself—but in healthcare, we work as a team. We work together to provide the best care we can to patients and I never utilized the team support that was available to me to help me process these events. Thankfully, I am lucky to be in a program where I get to work with my friends every day and it took support from my fellow residents, family and time during days off to reflect and face what I was feeling. It also took a thank you card from a patient’s family, to remind me that even if death can’t be avoided, there are still ways to help patients and their families.

Tory Toles, MD, is from Las Vegas, Nevada, and chose the University of Utah because it is an institution known for innovation and provides a diversity of educational opportunities, community involvement and strong commitment to care, all while located in an area with amazing natural beauty and outdoor recreation. Her medical areas of interest include medical education, office-based procedures, and reproductive and women’s health.. When not working, Dr. Toles enjoys indoor rock climbing, kayaking, hiking, cooking, and playing music.

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