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I’m a doctor. Preparing you for death is as much a part of my job as saving lives.

A reflection on my own medical education and what a good death might look like.

Photo of Shoshana Ungerleider
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It wasn't until just before graduation that we talked about what to do when a patient is dying. A single three-hour seminar with a group of specialists from the palliative care service; at least it was mandatory.

The presenters were young physicians, and they seemed kind and thoughtful. But I wondered why anyone would devote their medical career to end-of-life care. My classmates and I had spent years of medical school sharpening our history-taking skills, learning to recognize heart murmurs, memorizing the drugs used to treat high blood pressure, diabetes, even cancer. In the final months of school, I'd worked in the ICU, taking care of critically ill patients who required breathing tubes and life-sustaining machines. I'd learned how to perform intubations and place central lines. I marveled at how much I was able to do to help sick people. Nearly all of us became doctors to keep patients alive, to treat them.

I thought: The ultimate treatment failure is death. I graduated medical school and moved on.

Except for a cadaver in my first-year anatomy lab, I didn't see a dead body until the second month of my medical internship. When I finally did, it was my first overnight shift; I was the sole intern charged with cross-covering all of the medical patients. The pager never stopped beeping. I handled issues as they arose. I solved problems. But at some point in the night, a nurse called and said I needed to "come pronounce room 556." My heart sank.

I wasn't precisely sure what pronouncing a patient dead entailed. When I reached room 556, I entered to find a frail woman lying still on the bed. Mrs. Lee. She was surrounded by family members young and old, and, to my amazement, they were smiling, chatting, even laughing with one another. I mumbled a  greeting, then crossed to the bed, where I proceeded shakily through the pronouncement checklist in my intern handbook.

One of Mrs. Lee's daughters touched my hand. "This is my mother; she was a wonderful woman but had a long battle with Alzheimer's, and it was time for her to go," she said. "She just wanted to be comfortable in the end."

The other family members nodded in agreement and went on talking about how much they had loved Grandma Lee's custard buns and who would be getting her recipes. Mrs. Lee's family and friends, who had gathered around her to say goodbye, moved me. Mrs. Lee had had the forethought to tell them how she wanted to pass, and they were by her side until the end. I had never before pondered the idea of a "good death," but that night I walked out of room 556 with a smile on my face, because, somehow, I had just witnessed one.

When I was a newly minted doctor, I found myself back in the ICU, no longer a lowly medical student but with real responsibilities.

The patients in an intensive care unit are very sick; they require the highest level of monitoring and intervention that a hospital can provide. This particular unit was lined with patient care bays featuring sliding glass doors, glaring white walls, blinking monitors, and little natural light. Alarm bells dinged constantly, and the smell of bleach disinfectant made my eyes water. I began my rounds each morning at 5, checking in on my patients and learning about those who had been admitted overnight.

One morning, I came in to a commotion. There were several nurses scurrying around a new patient's bed, and the night residents were huddled in a corner, concerned looks on their faces. Before I had a chance to ask what was going on, a loud code blue alarm went off overhead, and the team of doctors descended upon the patient. I peered into the room, and underneath the breathing tube and profusion of lines, I saw an elderly man.

The senior resident called out orders. The intern hopped up on a stool next to the bed and began performing rhythmic chest compressions that cracked the man's ribs. The nurses pushed various medications into his IV and watched the heart monitor intently. I stared at the spectacle in front of me. This was my first time seeing a code situation. For 30 minutes I watched strangers in masks and gloves race around an unconscious old man, trying everything they could to keep him alive. But after the heart rhythm monitor fell into a flat line, the team pronounced him dead, removed their protective garb, and walked out of the room.

I later learned that an ambulance had brought in the old man for decompensated heart failure. His heart could no longer effectively pump blood to his organs, and he had been drowning in fluid that backed up into his lungs. On arrival, he was immediately intubated and rushed to the ICU. His family members were out of town, and he had not come with advance directive paperwork, a document stating his wishes.

This was not his first trip to the hospital. He had been admitted five times in the previous six months. During his first hospitalization, his records showed that he was a "full code" and that family had wanted "everything done" to keep him alive. Despite multiple readmissions, the question was never revisited. I wondered whether they knew what "everything" meant.

I learned that the old man was named Mr. Azarov. He was 88 years old, a widower, originally from Russia, where he had worked as a tailor and musician before coming to the United States. In San Francisco, he'd opened a bakery and had led a simple life. Over the months of his hospitalizations, Mr. Azarov had slowly deteriorated, and each time he became weaker. He battled kidney failure, a stroke, and worsening dementia. Well before he came to us for the last time, he had lost the ability to stand up on his own. His adult children were no longer able to care for him, and several months before he died they'd moved him into a nursing home.

I never knew Mr. Azarov, but I realized then that this man had been dying for a long time. He had a brutal, impersonal end, one he received by default. Who would die that way if they had a choice? Expiring in a hospital room, doctors screaming and scurrying and cracking your ribs, away from your friends and family — I wondered how many opportunities there had been to explain his end-of-life options to him or his family. Did they understand his prognosis? I'll never know. But as he lay there alone in the hospital bed, curtains drawn, still attached to machines, I felt as if we'd failed him.

One day, late in my intern year, while working the emergency room, I met a patient named Mr. Jones. He was a botany professor who lived in an affluent suburb outside San Francisco. He was married, with three grown children, and had the amazing fortune of good health over the whole of a long life. But now he was 72, and he was dying of small cell lung cancer.

Mr. Jones was receiving chemotherapy under the care of a reputable oncologist. He'd come into the ER that night because of severe, worsening shortness of breath that made him unable to walk across the room without collapsing. He told me his family was scared and so was he.

Before coming into the room, I'd reviewed his labs and chest X-ray and found that he had significant bilateral pleural effusions secondary to his lung cancer. This was a bad sign. When I came in, I saw that Mr. Jones had once been fit and brawny, although now he was worn and thin. We talked for a while. I asked the customary questions about his symptoms, and got the sense that he was a kind man. I explained to him that fluid had built up in his lungs due to his cancer, and that while we could admit him and remove the fluid with a needle, it would only make him feel better temporarily. I told him I believed his cancer had progressed.

I felt unusually at ease talking to Mr. Jones. After delivering the news, I decided to venture into unusual territory: I asked him what he understood about his diagnosis and his future. He explained that he had read online how he likely had only months to live, but that his oncologist wanted him to continue chemotherapy for now. Then I asked him what he wanted. To my surprise, he paused. After a moment, he looked up, tears welling in his eyes.

"I've had a wonderful life," he said. "I have an amazing family who loves me, and I want to be at home with them, not here in the hospital." He started crying. He grabbed my hand. "No one has asked me what I want. Can I please go home? All I want is to be home."

I was shocked. How could this be? I thought. How had we all failed to take a step back from the diagnoses and treatment options and the lab and imaging results to ask the most important question of all? Mr. Jones did not want to be admitted to the ICU. He didn't want to be intubated and adorned with the lines we use to sustain the dying. He knew there was no cure for his cancer, and he wanted what all of us hope for in the end: to die comfortably. With the help of the case manager and the social worker, I was able to send Mr. Jones home with hospice care early the next morning. I found out that he died in peace, two days later, surrounded by his beloved family.

I took time to talk to this man, to learn about his life and wishes. Together, we decided on a plan that fit his goals for his remaining days. The news of his passing gave me a sense of fulfillment. I felt relief that I had kept him from suffering. I thought back to the medical school seminar, and for the first time I understood why those doctors chose palliative care.

As doctors, we dedicate most of our time in medical school to learning about the physical body, how things can go wrong and how modern medicine can fix them.

During residency, we acquire methods for analyzing large amounts of data so that we can accurately assess, down to the minute, what is happening with our patients.

But we spend almost no time at all learning about illness in the context of our patients' lives, or how to heal people when modern medicine provides no cure. We are rarely schooled in how to break bad news compassionately, or how to sit in silence with a grieving family member, or even how to make recommendations for appropriate end-of-life care.

I have become disheartened by the number of patients who received invasive treatment in the final days and hours of life. So many spend their final moments hooked up to tubes and lines in the ICU, alarms beeping in the background, hidden away from the people who care about them. Modern medicine is always poised to offer another procedure or therapy for prolonging life, but it often does so without considering the quality of that life. How much suffering is five more weeks worth? Or five days, or five hours?

Today's physicians are spread thin. We have more responsibility than ever and are often tethered to a computer screen instead of at our patients' bedsides. Maybe it's easier to just give someone more treatment instead of stopping and telling her that she's dying. These conversations are never easy, no matter how many times you've had them. They can be enormously difficult even under the best circumstances, and often the circumstances are more like a patient (or, more often, his family) arguing, denying what's going on and demanding to see another doctor. Maybe we just don't want to go through it. Or maybe we hide behind more tests and procedures to make ourselves feel better — like we're still fighting. Like we haven't failed yet.

I don't see it that way. I believe we owe it to our patients to have open, honest conversations about what the future holds. Patients and families need to be informed in order to make decisions that are in line with their values.

My patients have all taught me valuable lessons about what a "good death" might look like. Each one has reminded me that there is more to medicine than placing a line to monitor the heart, or performing an intubation. Just because more tests and procedures exist does not mean that we should perform them all each time. Sometimes the most powerful healing of all comes through the simple act of sitting and listening to our patients with compassion.

We know that 75 percent of Americans would prefer to die at home. Only 20 percent actually do. We also know that 80 to 90 percent of physicians would not want CPR or mechanical ventilation at the end of life. Doctors actively choose to forgo the suffering that takes place in our ICUs, because we've seen it and we know better. My goal is to close this gap, to educate my patients about their options based on open, honest communication. I no longer see death as a failure but as a place we are all headed at some point — and if I can help someone live the fullest to the very end, I have practiced the best medicine.

This article originally appeared on, February 22, 2016

What is a provocation or insight that might inspire others during this challenge?

I want to share my personal experience of medical training in America in order to highlight the areas we can improve around end of life care in our education system.

Tell us about your work experience:

I work as a hospitalist physician.


Shoshana Ungerleider, MD


Join the conversation:

Photo of John

Dear Shoshana, much love and gratitude for your honest and accurate portrayal of the moment-to-moment decisions physicians face as death approaches. Experiencing the 'good death' of my wife's grandmother - at home, surrounded by loving children and grandchildren, lead directly to my work as an End of Life Doula volunteer. My evolving vision is based on the Palliative Care team (of which I am a part) which includes not only the medical professionals seeking to enhance quality of life, for the amount of time remaining, but family, caregivers, neighbors, friends. Earlier conversations, open and honest communication, breaking the taboo of discussing death in the specific, and a cultural awakening of death as a necessary and meaning-making part of life, will go a long way to reduce uncertainty and clarify the dying person's wishes. And maybe a DNR tatoo (or chip, God help us!).

Photo of Paul

Shoshana - A heartfelt and courageous post. None of it was lost upon me. As you know, my folks were some of the lucky 20% who did get to die at home with much dignity. Whatever the confluence is that this challenge ends up becoming - I would welcome the opportunity for further discussion and collaboration. I dealt with a fair number of Dr.'s while serving as my folks' patient advocate. BTW, many were members of the Sutter Medical family here in the North Bay. And, as someone who was responsible for taking care of the Home Death Care part of the equation - once my folks were no longer going to be subjecting themselves to institutional medical interventions - I know full well that one does not just float off merrily into the sunset when they walk out of a Dr.'s office towards home. The Home Death Care component of the process is no less fraught with fear, pain, confusion, etc. There are the positives, which we both understand, and there is still hard work that needs to be done by all concerned 'cuz yea - someone's dying. I'm happy to be engaged in this process. We'll see where it leads as time rolls us all along. Best. - PWE

Photo of James

Shoshana, thank you for such an amazingly vivid and heartfelt post. As an emergency physician I could not agree more. Time pressures abound in medicine and marginalize meaningful discussions of goals of care and making people comfortable rather than giving them a few more hours or days to live at the end of life. I am always surprised by the frequency of last minute decision making in chronically ill patients who suffer an acute decompensation and come in with no advance care directives.  One family member once said, "we knew she was sick but we didn't think she would get so sick so fast.  Is this reversible?  Can we get more time?"  Medicines answer is "yes, maybe" but that decision often leads to the medical used death you describe so clearly.  We should be having these conversations well in advance of acute illness to ensure that family and patients are committed to responding "no" at the end. 

Photo of Chiara

"I have become disheartened by the number of patients who received invasive treatment in the final days and hours of life. So many spend their final moments hooked up to tubes and lines in the ICU, alarms beeping in the background, hidden away from the people who care about them. Modern medicine is always poised to offer another procedure or therapy for prolonging life, but it often does so without considering the quality of that life. How much suffering is five more weeks worth? Or five days, or five hours?"

Absolutely touched by your words. There is so much truth in what you have written. Thanks for sharing your experience and your insights. I was moved by the stories!

Photo of Jules

beautifully said.

Photo of Sue

Shoshana, thank you for these thoughtful and humble insights. It strikes me that medicine plays such a major role in both birth and death in our culture. Of course, medicine has contributed greatly to the safety of birth and the comfort (in some cases) of death. But medicine needs to be at the service, not the focus, of these powerful events that will take place with or without medical intervention. This requires education and a shift in understanding that the end of life is not a tragedy - it's what happens to all of us, and we should do all we can to make that transition as peaceful and positive as possible. Thank you for recognizing this and being a part of a more humane approach to your patients' deaths.

Photo of OpenIDEO

Congrats on this being today's Featured Contribution!

Photo of James

Hi Dr. Ungerleider - thanks for this article and your refreshing viewpoint. You mention "How much suffering is five more weeks worth?" which hits a nerve I think - this idea of that our lives are worth fighting to be alive for, that to die is to somehow give in. It seems like a narrative problem - a story we tell ourselves, or want to be told about us - "she fought hard, she was a fighter" kind of thing. There is a wonderful program run by Dr. Chiron at Columbia called the Program in Narrative Medicine which looks at the stories of illness, witnessing, and end-of-life: as experienced by both physicians and patients. Your insight that the "most powerful healing of all comes through the simple act of sitting and listening" seems to be right on with her philosophy. I would love to see some explorations of end-of-life narratives as part of the ideas phase.

On a more practical note, in your story you say "he had not come with advance directive paperwork, a document stating his wishes." I wonder if the designers involved in this challenge will pick up on product design cues like that ... how should people bring in their paperwork - is it something that the administrators process? what about if they are coming in rushed through the ER? Is it a bracelet that those near death are wearing with a display, or a control like a barcode or RFID that would trigger a download onto the physician's tablet? If it is uploaded to an EMR like Epic, are the rounding team seeing that the paperwork is there - for example is it hidden deep in the menus of the user interface, or easy to find on the homepage of the chart? just some thoughts. Thanks again.

Photo of Anne-Laure

Shoshana, thanks for this reflective, detailed and thoughtful post on your education and practice as a doctor. You highlight very well some limitations and frustrations family members and friends might experience, but also unveil some of the reasons behind it (current education and training, focus of medicine on "saving life" vs. "taking care of patients" - with all the variations this might mean; the system's constraints - e.g. "physicians are spread thin"). 
The scenes you described reminded me scenes from a French movie, Hippocrate: Diary of a French Doctor

You might want to check this post
as well as this one:

I believe your post opens up important directions for the ideation phase regarding training and "definition" of a doctor (or nurse)'s role. It also suggests the need to think of how to support doctors in  their helping patient.

Photo of Mansi

I think you hit the nail on the head when you said "Nearly all of us became doctors to keep patients alive, to treat them" Very often doctors tend to almost forget to offer the patient "doing nothing" as an option. I think as humans we feel guilty when we talk about "allowing" our loved ones to die and we often forget that a peaceful death surrounded by those they love is what most of us would choose. 

You have uncovered a powerful insight in seeing that somewhere medical professionals may not be talking about these options often enough. What do you think we can do to change this attitude? Have you come across any ideas that have worked in successfully getting doctors to speak to their patients about these options?

Photo of Shane

Thanks for sharing this thoughtful story about your experiences Shoshana! To echo Mansi's comment, we've seen a number of insightful posts from care professionals expressing the internal conflict they feel between doing what is expected and what patients wish for during end of days. Death on the ICU and Quality are just a couple of stories from health professionals that highlight the need for better communication between doctors and patients. And like Mansi said, we'll look forward to exploring new ideas around how more doctors can be supported to speak openly to their patients about end-of-life options:-)

Photo of Marije

Thank you for sharing your amazing insights.