Our patients’ final chapters: Coming to terms with end-of-life care
Our Patients’ Final Chapters: Coming to Terms with End-of-Life Care
By Shivali Shukla
I don’t know how her story began, but I know how it ended.
She arrived with an external compression device already pounding rhythmically against her chest, at least 120 times per minute. The on-call emergency department provider placed a central line as the OB/GYN shouted, “Incision.” She was 37 weeks pregnant. Her uterus had ruptured. Her baby was pulled from her distended belly, APGAR scores of 0 and 2. The baby was rushed away by the NICU team standing by. I watched them close the patient’s incision. They placed a chest tube. I listened as she was pronounced dead within minutes.
It was my second day in the emergency department as a third-year medical student, and she was my very first witnessed code. The trauma call came in, and within minutes, she was wheeled through the ambulance bay doors. My attending had to explicitly tell me I was allowed to enter the trauma room. I hesitated, overcome by a sense of reverence, as if I were intruding upon a profoundly intimate and sacred moment. The hallway buzzed with hushed voices and frozen glances. A nursing student beside me struggled to stifle her sobs. That’s when I felt the sting of tears welling in my own eyes.
As the urgency faded and minutes stretched thin, the hallway emptied. Only one nurse remained in the patient’s room. Yet I stood there, immobilized. I felt a strange, solemn duty to stay. We had all borne witness to what felt like the most exposed and vulnerable moment of her life. And now we were to simply walk away?
Eventually, I summoned the courage to leave and headed straight for the bathroom. I locked the door and let the tears fall – for perhaps twenty seconds. Then I stopped. I was startled by the intensity of my own reaction. This wasn’t about me. I had a job to do. So, I splashed cold water on my face, straightened my coat, and returned to my desk, mentally preparing myself to see my next patient.
Among the most profound challenges I’ve encountered during clinical rotations has been reconciling the moments when we’ve exhausted all viable interventions. Watching a patient decline due to DNR status, initiating a palliative consult, transferring someone to hospice rather than home, or gently informing families of a grim prognosis – it all felt unfair. It felt like surrender. It has taken time and reflection to accept that sometimes, offering comfort is the most compassionate form of care we can provide.
During my first week on the internal medicine wards, we admitted an elderly gentleman presenting with altered mental status. Just a week prior, he had been hospitalized for bacteremia and fungemia. He completed a full course of IV vancomycin and meropenem, and was discharged to his skilled nursing facility, only to return the following week with identical symptoms. This time, however, we were unable to identify a source. Blood cultures, imaging, labs – all inconclusive. We treated him empirically, and gradually, his mental status improved. I interpreted this as progress, even hope.
Yet our team still contacted his son to discuss goals of care. After several days of thoughtful deliberation, the family opted for comfort measures.
I wrestled with that decision. In my mind, the patient was improving. We had stabilized him – hadn’t we?
It wasn’t until my attending gently laid out the broader clinical picture that I began to understand. This man’s health was in inexorable decline. He would continue to return with recurrent infections; his immune system was failing. His delirium would progress. Our interventions, though well-intentioned, risked causing more suffering than relief. Medicine, when misapplied, can wound as much as it heals.
When I was tasked with revisiting code status with a patient I had cared for more than 26 consecutive days, I felt a deep sense of anxiety. It felt as though I was ultimately asking this woman, whom I had gotten to know quite well, if she was ready to die. But after closely following her hospital course week after week, I understood exactly how each new intervention resulted in further complications, increased pain and continued to extend her hospital stay. This time, I understood we had exhausted almost all options. This time, I knew why we needed to have this conversation.
Even before medical school, I carried with me the belief that each patient carries a story, and that their illness is only one chapter within it. I’ve found purpose in learning about my patients’ values, beliefs, fears and aspirations, all while striving to address their physical ailments through evidence-based medicine. “Patient-centered care” has long been a guiding principle in my approach.
But I realize now that I misunderstood part of its meaning.
True patient-centered care requires knowing not only when to act, but also when to step back. It means understanding that the patients admitted to the hospital are perhaps the sickest they have ever been. It means honoring the wisdom patients and families bring to the table. Sometimes, the most courageous act of care is recognizing when continuing treatment no longer serves the person before you. And that’s not a decision any single one of us should make alone.
I will never forget my very first code. The memory of her 1-year-old son crying in a nearby room will stay with me forever. So will the sobering realization that compressions, ventilators, and aggressive pharmacologic interventions – while powerful tools – are not magic. They are not a promise. They are not a guarantee. They are only part of the story.
Shivali is an M4 at UICOMR
sshukl5@uic.edu