Tuesday, September 20, 2011

Killing patients

I have never killed a patient.

I've had patients die on me many, many times, but I've never been involved in a situation where I felt that I did something (or didn't do something) that caused premature death. Every time I cross covered the hospital as an intern, I would pray to get through the night without harming anyone. I know a lot of doctors who haven't been so lucky though. Recently, another doctor was telling me about how in residency he gave a little old lady 2 mg of Ativan and she never woke up, and he felt guilty about it all the time.

They say that there are 2 kinds of doctors: those who have killed a patient and those who will kill a patient. (I think I heard that on Scrubs.)

I'm hoping that as a physiatrist, it won't happen to me. Now that residency is over, I actively try to avoid situations where I could end up being responsible for a death. Yet another reason why I couldn't have become an OB/GYN: how could you deliver a dead baby (inevitable) and not blame yourself for the rest of your life?

I've heard a lot of stories of doctors who felt responsible for the death of a patient and subsequently ended their career. When I did pediatrics, I heard about an attending who missed a case of appendicitis and the child died. The pediatrician quit medicine, even though the mother didn't blame him and continued sending her other kids to the practice.

It's a hard job. Please don't tell us we're overpaid.


  1. It sucks. I still remember the ones from residency and it's been nearly a decade.

  2. I remember giving an end of life patient PO liquid morphine for the first time. I think I sped her journey along.
    As a nurse and carrying out doctors orders for comfort care over the years; i.e., keep increasing the morphine drip Q 1/hr until the pain controlled (dead)
    I know the nurse usually feels bad because the family is present, but how do the doctors feel about writing these kind of orders?

  3. NP Odyssey, I feel a lot better about writing these kinds of orders when they conform with the wishes of the family and the patient than I do about watching a patient drown in his/her secretions, screaming, "Help me!" repeatedly because the attending "doesn't believe" in palliative care.

  4. I think it's a pretty common misconception that using opioids for pain hastens death. There have been many studies showing that if opioids are used appropriately, they are safe. If anything, treating someone's pain adequately probably increases lifespan.

    Almost everything we do in medicine has a risk and a benefit. Not treating someone's pain adequately because of the small risk of respiratory depression (which can be reversed with naloxone and is usually preceded by other signs) is kind of like not doing an angioplasty on someone with a massive STEMI because there's a tiny risk of bleeding or death.

  5. Liana: If we define appropriately as "in a way that provides pain relief without hastening death" then your claim is both true and meaningless. If however we define adequate pain treatment as "giving a dose which relieves the patient's discomfort and would not ordinarily be lethal" there will be some weak terminal patients for whom an adequate dose will cause fatal respiratory depression. In such a case giving naloxone to a patient who has a DNR and received a dose appropriate to his level of pain is a little cruel, especially if the patient has been on opiates long enough to develop dependence. This is an issue families and physicians should talk about, not pretend it doesn't exist.

  6. Phillip: It's been my experience that in palliative care, undertreatment of pain is far more common than overtreatment of pain. I do think that fear of hastening death is a significant reason for undertreatment of pain, and I agree with you that physicians and families need to discuss this carefully.

    The studies that have been done suggest that the risk of hastening death is low. I'm not sure if I'm misinterpreting your statement, but it sounds like you're saying that it's impossible to achieve adequate pain control without causing opioid toxicity. I would disagree.

  7. Well, I wasn't really thinking about palliative care, rather I was talking about unintentional death. I have removed patients from life support (or at least, given the order to do so), but I feel that falls into the category of "letting the patient go" rather than accidentally killing them.

  8. During my last year as a med student, I did a two month internship with a paedriatric ICU team. For me, it was one of my significant internships, where i had the chance of learn academically, ethically and personally.

    In my short experience there, the most traumatic decision of witnessing a "letting go" decision was with JH, a 4yr old boy with a traumatic locked-in syndrome. After two weeks in the ICU, the double confirmation of extensive neurological damage and a destroyed family, the boy developed a septic shock and both parents and the medical staff took the joint decision of "letting him go".

    I was never directly involved in the process of decision making, but for someone who followed the patient from day one and dealt with the parents everyday, it was a draining experience at best. It forced me to mature, to acknowledge that medicine may prove itself useless in some scenarios, to gain respect for both impairment and death and to appreciate how hard is to make a decision concerning someone's life.

    But even if this decision was taken by the parents and the senoir staff on the grounds of "what is best for the patient", every once and then I find myself wonder if we really "let him go" or if we killed him instead... and I can't help but feeling uneasy about all this.

  9. Just to nip this side-note in the bud, the Double Effect is something that is commonly misunderstood.

    I have witnessed withdrawal of care and felt relief. I have participated in withdrawal of care and felt guilt. I have never felt that it was inappropriate to follow the natural path of life and death when sometimes we are caught up in physiologic functions (i.e. pulseless electrical activity).

    Going back to the subject at hand.


    Great, now I'll be worried EVERY TIME I give someone 2mg of Ativan. :(

    Luckily, I haven't been involved in the unexpected death of anyone during my intern year. I had to edit that sentence from "killed anyone" because, like you said, families aren't as hard on doctors as we fear they are or would be, in comparison to how hard we are on ourselves.

    In combat, they call in Survivor's Guilt when someone else dies and you wonder why you deserved to live. In medicine, there should be a name for something similar for the type of psychic trauma that comes from feeling personally responsible for the death of someone and you wonder if there was anything you could have done to stop it. Prescriber's Guilt, maybe?