In respectful memories of Benson, Rose, and Sandy. I want to thank each one of them for helping me become a better physician.

I stepped into the intensive care unit with a feeling of apprehension. I knew deep down, the patients I was going to care for were sick patients. Their status could change at any time. This was my first week on the ICU as a resident physician.

Benson needed emergent blood transfusion. He gazed up at me, reached out for my hand, and I held his hand while he was being poked multiple times, his veins chronically fibrosed by all the central lines that have been placed in past. Rose, who needed open heart surgery, told me she wanted a hot young cardiothoracic surgeon when instead, an older not so good looking surgeon stepped into the room. We both laughed.

Suddenly, my pager went off. I dialed the number back and asked how I could help; the voice on the other end announced my patient Rose had passed away on the operating room table. I was breathless, not expecting this bad news, in shock, tears running down my face. I was just laughing with Rose and hour prior. I couldn’t believe that she passed so suddenly. Benson had passed the night before after 1 hour of CPR. Just like that, two of my patients who had touched me more than I had known, went in peace.

As I was upset, I found a lot of comfort in my colleagues and staff around me. I received pats on my back, hugs, comforting text messages. Needless to say, our program is like a high school and news travels fast. But I could not be more thankful for everyone’s kind words. Many residents told me they too, got emotional when their first patients died. I kept asking myself, just how do you learn to cope?

With death being a taboo topic, patients wanting to be full code, meaning cardiac and respiratory resuscitation, and the advances of medicine providing longer lives to patients, death is to many physicians, a failure. While I stood amongst my class at medical graduation and promised to primum non nocere (“first do no harm”), I can see that, when addressing terminal diseases and end of life care, there are no algorithms to follow.

My medical school training offered one simulated patient lab during my third year of training with the purpose of teaching us “how to announce bad news.” On the paper I had picked, the short scenario read, “You are here to discuss the CT findings with your patient, a large 8 cm lung mass was found suggestive of cancer.” I stepped into the exam room with that same feeling of apprehension I entered the ICU. I knew once I announced the imaging results to my patient would illicit a reaction I would not be able to control, and more questions, and maybe denial or anger.

What you cannot control scares you.

One of my pulmonary critical care attendings said,”Ethics: If I can go to sleep at the end of the day, I know I have done the right thing.”

However, I have to disagree with this statement. You cannot just rely on your gut feeling. Every case, every patient is different. When speaking about end-of-life care four entities come into play:

1. the purely medical aspect which is how far can you go to prolong life
2. affection and family
3. religion, culture, and moral values
4. the financial aspects of death and dying

When speaking with your gut feeling, you might forget to take into account the patient of family’s wishes. Let me illustrate this with another case.

Sandy was a woman in her seventies, recently diagnosed with metastatic breast cancer. She was receptor positive and therefore had a better prognosis undergoing chemotherapy treatment. She received one dose of a small amount of chemotherapy and had a bad reaction; she ended up in the ICU in sepsis and multi-organ failure. Not only was this a very recent diagnosis and the patient and her family were still in denial, the prognosis was poor right when she entered the ICU. Standing by my attending, listening to how he was discussing code status and prognosis, the patient still needed time to think about this. She kept saying “I don’t want any more chemotherapy, but I want to live.”

A couple days later, Sandy started to throw up clots of blood. The situation was urgent. We either had to intubate her to protect her airway or change her code status to do not resuscitate and treat her with the comfort of morphine that would relieve pain and slow her breathing. Sandy said she did not want a tube down her throat, and she did not want to be on a ventilator. Discussion went on for 2 hours involving Sandy, her family at the bedside, my senior resident, attending physicians and her nurse. We knew that if she didn’t get intubated she would pass away.

Sandy said she did not want to die, but she continued to refuse intubation. I watched my senior resident whose cultural background pushed to do everything possible and the nephrologist who knew her for a long time, expression of helplessness had overtaken them.

What you cannot control scares you.

Our patient was dying in front of our eyes, and she was refusing what would help her stay alive. Stay alive? But at what quality of life? Did we forget Sandy’s wishes?

Sandy’s code status was changed, and she passed away surrounded by her beloved family members.

My time in the ICU was definitely challenging. I will not forget Benson’s hand holding mine, Rose’s laughter, Sandy’s courage. With little preparedness in my training, I was exposed to the blunt reality of death. As resident physicians, this was part of our training. Tears are shed, some say you become numb, others develop coping methods.

However, as I reflected, I was enlightened by the opportunity in death, and not so much afraid anymore. Through these experiences, death shed light on values of respect, communication, truthfulness and honesty towards one another. I learned to guide and support patients and their family members in difficult decision-making and always respect their wishes. Death is the natural succession to life, and still the time of death remains unpredictable, but learning how to speak about death made me understand what really matters in the end.

Emilie Y. Prot is an internal medicine resident and a member, public health committee, resident and fellow section, American Medical Association.