As an advanced heart failure and transplant cardiologist, I witness plenty of tragedy. But I don’t lay awake at night anymore grieving bad outcomes — that is the privilege and purview of loved ones. While family and friends may move through Elizabeth Kubler-Ross’ classic stages of grief, doctors do not have that luxury. To give tragedies a purpose, I take three steps when faced with bad outcomes: Separate fault from fluke, separate the expected from the unforeseen and make peace with what I cannot control.
The first step: Ask yourself, “Was it my fault?” Identifying yourself as the proximate cause is gut-wrenching. When I was a cardiology fellow, a patient with a mechanical aortic and mitral valves presented with symptomatic bradycardia and underwent pacemaker placement. The next morning, she was bradycardic and hypotensive. I spent precious minutes checking an echocardiogram to assess for a pericardial effusion (the wrong move, as tamponade would have resulted in tachycardia, of course) when she had an inferior ST-elevation myocardial infarction caused by an embolus down the right coronary artery. She passed away in the cardiac catheterization laboratory, and I replayed her case at two o’clock in the morning for weeks afterward. If I had not wasted time getting the echocardiogram, would she have survived? Probably not, but I’ll never know. But I’ll also never forget that a coronary embolism can occur in patients with mechanical valves.
The first step continued: If after conversations with your trusted colleagues and mentors, you establish that the bad outcome was not your fault, then you cannot change your practice based on it — so-called “doctoring by anecdote.” Because one patient sustains a subdural hematoma while on anticoagulation for atrial fibrillation doesn’t mean that the next three patients with atrial fibrillation and a CHA2DS2-VASc score meriting anticoagulation should not receive it. Doctor by guidelines, doctor by clinical trials and doctor by experience. Do not allow bad outcomes to make you doctor by anecdote.
The second step: Ask yourself, “Could I have predicted this?” While bad outcomes are always horrible, unexpected bad outcomes are worse. (This is one of many reasons why I hold obstetricians in high regard; labor appears equal parts miracle and imminent disaster.) In the high stakes world of advanced heart failure, patients by dint of walking into my office have a dismal one-year life expectancy. Though patients and their families know that tragedy can strike at any moment, that doesn’t mean they understand how difficult the road to recovery can be. A patient with cardiac sarcoidosis and VT storm was referred to me because his local transplant center considered him too complex for transplantation. He flew across the country, imagining a few months to wait for a transplant and a few more to recover before returning home. But he decompensated on the waitlist and months later, after sepsis, renal failure, and a massive stroke, he died in our intensive care unit, far from home, with only his wife at his bedside.
She was strong and stoic and grateful, but I felt we failed him. He had not realized that his journey could end the way it did. I work much harder now to prepare patients and their families for the worst-case scenarios.
The third step: Make peace with what you cannot control. A young woman had sudden cardiac death while crossing the street and was placed on extracorporeal membrane oxygenation support. Over the next week, she developed Klebsiella sepsis, an ischemic leg requiring amputation, and liver failure. At daily family meetings, her father took meticulous notes, as if knowledge could reverse his daughter’s multisystem organ failure. But it did not, and she died. There was a surreal moment when I exited the family meeting where we decided to withdraw interventions meant to prolong survival. I ran into a healthy outpatient who let me know that she wasn’t happy because my office hadn’t faxed records to her internist — the starkest reminder that life goes on, and I did not have the luxury of grief. I was not the proximate cause in this young woman’s death, and I had done everything I could to prepare her family. I gave myself permission to let it go. Holding on to my grief would help no one, least of all other patients who needed my help (or at least, my clerical skills.
And an addendum to these steps: When a patient has an amazing outcome, don’t just bask in the warm glow of success, figure out what worked. A patient status post knee replacement had a near-syncopal episode. I heard a right-sided S3 gallop so ordered a V/Q scan that showed multiple pulmonary emboli. I was so proud of that save. I listened for right-sided S3 gallops on every patient after that, though the real lesson was not to listen for an S3 in every patient — it was to listen to my gut. A minimizer by nature, I would have written off his presyncope as hypovolemia or a vasovagal reaction to post-operative pain. But the patient’s fear and agitation made me uncomfortable. That lesson, to dig deeper if something doesn’t feel right, has served me well in years to come.
My heart has been broken many times by tragic outcomes, but I cannot let them all keep me up at night. So I try to separate fault from fluke, expected from unforeseen and accept that I’m not in control.
The author Rita Mae Brown wrote: “Good judgment comes from experience, and experience comes from bad judgment.” Our task, as doctors, is to dissect bad outcomes, identify bad judgment and distill it into the experience shapes good judgment. Grieving bad judgment and making peace with bad outcomes is the best way to heal ourselves.
Michelle M. Kittleson is a cardiologist.
Image credit: Shutterstock.com
