Codes of Care

Mr S is my favorite patient at the VA. This might be because of his smile, his tolerance of my amateur poking and prodding, or his meme-worthy Dad jokes. Or all of the above.

I am in my last week with the hospitalist team. Mr S is on nasal cannula again and his pathology workup is back. Pancreatic cancer. The family meeting is scheduled for 3 pm.

This all feels profoundly unfair. Mr S and his sons all have the same warm demeanor, belly-laugh, and prolific facial hair. This morning, they are half-bemused, half-apologetic when Mr S calls me “nurse Sophie.” In response, my resident and intern immediately correct him, explaining that I am, in fact, training to be a physician.

After lunch, in the midst of discussing differential diagnoses of acute chest pain, we hear a series of codes overhead. Gray, for someone trying to leave against medical advice. Red for fire, likely a false alarm from the break room microwave. Blue, for a cardiopulmonary arrest somewhere in the hospital.

After didactics, I return to the hospitalist workroom and find my resident in his usual spot. But his grin has evaporated and his eyes are somber. I open my mouth, but he speaks first.

“Mr S died.”

“You. What? You're . . . joking.” It takes me a moment to realize I just said that last sentence aloud.

“No, I'm not. That was the code blue called while you were in class. He started spewing up coffee ground emesis and went into cardiopulmonary arrest. I'm glad we made him DNR/DNI yesterday.” He looks down at his feet. My eyes follow his. His brown brogues are sodden. “The vomit got on my shoes,” he adds quietly, more to himself than to me.

“Can I go see him?”

The question comes as a surprise to both my resident and myself. “Yeah, of course. Do you want me to come with you?”

I shake my head no and walk to the patient's room, hesitating outside the door. The words of our preclinical instructor echo in my head. If you are crying for yourself, keep it out of the room. But if you are crying for them, don't be afraid to let it show. I enter.

Mr S is crumpled and so much smaller in death. His sons are at his side, still a little blank with shock, but also at peace. One of them shows me a selfie he took with his father that morning. Mr S is smiling behind his oxygen mask and giving 2 thumbs up—typical Mr S.

I brace myself and say, “I'm so sorry for your loss.” I add in a rush that Mr S was a really lovely person and everyone on the floor liked him. My voice cracks, and my vision blurs with tears. His sons look at each other, then back at me. A question and a shrug pass wordlessly between them.

“What was your name again?” one asks. When I answer, they remember me from this morning. Then, to my utter embarrassment, the older son gets up and hugs me. I have a vague feeling of intense guilt, a pang of alarm. We are supposed to be taking care of the patients, not the other way around. In the end, I wasn't even been there for Mr S's passing.

I flashback to the last time I was close to a death. A year prior, my friend Yan—28-year-old-male, brazen, fearless, the best kind of crazy—died in a car crash. It happened on the other side of the country, and his body was not at the service I attended. This was a mixed blessing. I didn't want it to feel real, but at the same time, the lack of evidence made the proceedings feel pantomimed and distant.

Suddenly, I understand why it was important for me to see Mr S after he died. I wanted to face his death openly and deliberately. I wanted his family to know that I cared about him and would remember him. And, selfishly, I wanted to give myself a chance at closure.

The rest of the day ends in a blur. When I finally get home, my phone buzzes. It's my intern, texting to ask if I'm okay. An hour later, it buzzes again. It's my resident, asking the same question. Shortly afterward, it rings outright. It's my attending. He wants to check in, debrief me about Mr S's death. He wants me to understand, as much as possible, what happened and why. Before hanging up, he tells me to take care of myself. The nicety carries newfound weight for me. I feel more a part of the team than I have all year.

I am tired and wrung out but also have a sense of rising hope, conviction, and strength. I am reminded of what my friendship with Yan taught me. How to hold on to my sense of self in the face of adversity. How kindness is a form of bravery. That it is possible to be ambitious and strong and vulnerable all at once. These values shape the kind of person I want to be, the kind of physician I aspire to be: competent, empathetic, and selfless. I realize Mr S and his family have taught me something too—that it is okay for physicians to show their emotions, and that “strong” does not have to mean stoic.

As the medical education community asks itself if empathy can be taught, cultures shifted, and burnout thwarted, I find answers in my experience at the VA. A patient who I connected with died unexpectedly, but I did not go home early or take a personal day the next morning. Instead, I was eager to return to work. This was made possible by the way my team advocated for and supported me, by the comfort that my patient's family offered me in the midst of their grief. Mr S's final gift to me, like Yan's, is bittersweet and lights my path forward.