I squeezed my toes against the top of my shoes and splashed some cold water on my face. It was a technique I had perfected as a medical student to stay awake late at night while studying for my constant examinations. This maneuver, repeated throughout the evening as I drank cups of coffee, would hopefully sustain me as I trudged through my 30-hour intern call.

“Beep-beep-beep.”

I glanced down to check my pager, which seemed to make noise more than it was quiet during those terrifying shifts alone on the medical wards. I called the unit and the nurse quickly reported that I needed to come to the floor as one of the patients had the “death rattle.” This term is feared by all of my colleagues as it is commonly a signal of impending death as saliva accumulates in a patient’s throat.

As I quickly ran up the staircase, I fumbled through my multiple sign-outs, a list of patients’ diagnoses and treatment plans that the other interns had passed to me before they left the hospital.

The patient was a 92-year-old female with dementia who had a long list of medical problems surpassed only by her multiple medications. I grabbed the chart and confirmed her Do Not Resuscitate (DNR)/Do Not Intubate (DNI) orders as I entered the room. I gingerly placed my fingers on her wrist to check for a pulse. Nothing. I twisted my stethoscope to auscultate for heart sounds. Nothing. The nurse confirmed her death, and we quietly exited the room.

I asked the staff to procure the “death paperwork,” a series of documents that are filled out with black ink to confirm a person’s passing. We had spent two hours reviewing this task during my initial hospital orientation. During that session, I had found it odd as a future psychiatrist that no time had been devoted to helping us deal with our emotion reactions to the loss of a patient.

While I waited, I fumbled through the patient’s chart searching for a family phone number to notify them of her passing. I sifted through my memory for any lessons I had learned in medical school about dying. Did I sleep through the lecture on how to call a patient’s family at 2 a.m. to tell them their mother had died?

A sharp pit began to grow as I went to pick up the phone — I had failed as “my patient” had died. I had devoted four years of premedical sciences in college and four years of medical school to care and save patients. Each course was oriented to teach us how the body works in hopes that we could avoid its demise. The goal of life had been set. Death was the enemy and the worst of all outcomes in medicine.

“Ring ... ring ... ring ... You have reached the voicemail of ... .”

I quickly hung up the phone in search of another number to call as I churned over these inherent principles of my health care training.

Why was it that I could help bring a baby into this world but had no knowledge on how a person leaves it?

I began to compare my training to that of a pilot who had been trained to take off and fly a plane but had no knowledge of how to land it. Was the descent a moot point? Were all of my patients passengers who would never be grounded? Could their arrival at a new unknown destination only be seen as a crash?

The loss of “my patient” had made me feel inadequate as a doctor because this result had never been discussed in the classroom and thereby unconsciously viewed as a mistake to avoid at all costs. I felt ill-prepared to face this dark path alone in the middle of the night, but there was little choice in the matter.

“Hello?” whispered a female voice on the other side of the line. “Um, hello, my name is Dr. Buxton, and I am calling about your mother.”

“Hold on a second. ... Yes, what happened?” she replied.

“I am so sorry to tell you this over the phone, but your mother just passed away. She was sleeping and did not appear to be in any pain.”

And then there was silence — dead silence on the other line. I took a deep breath and waited.

“Thank God. I know that is weird to say, but I had been praying for her to pass. She has not been herself for years with the dementia. I am happy she is in a better place. I will head over to the hospital now.”

I put down the phone and looked out the window until the nurse arrived with the paperwork. My patient’s death had not been seen as a failure to her family member but was met with a sense of relief. Here was my first lesson in my medical training about death.

Dr. David Buxton works with Insight Physicians at CJW Medical Center and is a clinical assistant professor at VCU. He completed residency in adult psychiatry at Brown University and child and adolescent psychiatry fellowship at Harvard University. Buxton was the first psychiatrist to graduate from Harvard’s Palliative Care/Hospice fellowship. He has lectured on the topic of palliative care and psychiatry at local, national and international conferences.

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