In Practice: Reflections from NPs and PAs

Harrison Reed, PA-C, practices critical care medicine in Baltimore, MD.

I don’t remember the first time I watched someone die. I don’t remember the second or third time either. But I know it happened when I was 24 years old, and I know that, afterward, I went home, ate dinner, and went to sleep. The next morning I woke up, put on a clean pair of scrubs, and did it all over again.

Before I could even grow the scruffy hint of a beard, death had become a constant companion. But that didn’t mean participating in someone’s death ever felt routine, or that I grew numb to its significance. If anything, the effect was the opposite.

The more I encountered death, the more I saw it as an important chapter of life. And I made it my duty to ensure that my patients and their families navigated this often-saddening event surrounded by as many positive experiences as possible.

But as a brand new physician assistant in the intensive care unit of a mega-hospital, that desire was no easy accomplishment. A medical ICU at an academic center invites the intersection of two conflicting concepts: the close bonds that can form between clinicians and patients (or their families) over a prolonged hospitalization, and the factory-style shift work that keeps the entire process functioning.

That concoction produces the same scenario time and time again: we meet people with their every vulnerability flayed open to the world, guide them through their personal hells, and tear ourselves away at the end of their lifespans or the end of our work week, whichever comes first.

For patients and families, it must feel cruel. On the other side of that hospital bed, they may have found a friend in the most unexpected way, only to have that person vanish at the worst time. Then a new stranger appears, ready to restart the process.

That level of interchangeability clashes with the intimacy of death. At this most significant time in their lives, we pummel our patients’ families with a barrage of white coats.

The idea of dehumanizing medicine, especially at the end of life, began to bother me so much that I wondered if critical care was the right field for me. In my search for consolation, I found an article written by Dr. Gregory Kane. In it, he described a bygone tradition once commonplace in medicine: the letter of condolence.

By writing a letter to deceased patients’ next of kin, Dr. Kane argued, clinicians can offer families an irreplaceable level of support. We can reassure them that their loved one’s life was significant and that he or she mattered to the medical team not just as a patient, but also as a person.

Soon after I read Dr. Kane’s article, I faced a particularly difficult experience saying goodbye to a patient and her family. It was the first time I had considered writing a letter of condolence, but it seemed more appropriate than ever. I later detailed the entire experience in my essay “The Letter.”

To many people, this act probably sounds overly sentimental. Any kind of attachment might be unwise, or it might be seen as a sign of weakness. Despite the occasional lip service, our medical culture doesn’t place a premium on emotional sensitivity. Besides, isn’t letter writing out of fashion?

As those doubts grew, I decided to write a second letter. This one was to Dr. Kane. I told him how much I appreciated his advocacy for the letter of condolence and how writing one myself had convinced me of its value. I also said that I hoped the idea would see a resurgence, that it might catch on with a new generation of medical providers, but I worried I couldn’t convince others to spend precious time and energy on such a task.

His response was, unsurprisingly, wise.

Just share your experience with anyone who will listen, he said. “That will say it all.”

And now I have.