Words Unsaid
This story is drawn from real experiences. Protecting my patients’ confidentiality is of utmost importance to me; names, details, and timelines have been changed to honor their privacy, and any similarities to actual persons or events are purely coincidental. The emotional truth remains intact.
“You killed our son.”
They didn’t actually say that, of course, but that’s what they meant.
Dear Dr. Dael;
Please be advised that this firm represents the parents of Jonathan M., deceased. This letter serves as formal notice of our client’s intent to pursue a claim for medical malpractice arising out of the medical care and treatment you provided to Jonathan M., which resulted in serious injury and death.
We request that you place your professional liability carrier on notice immediately and preserve all records, notes, and materials related to the care and treatment of Jonathan M. Further communication regarding this matter should be directed to our office.
The echo of those words will be with me forever.
During my Pediatric ICU rotation as a senior resident, I was called to the floor one afternoon for a consult on a gravely ill patient. Jonathan was a young man in his early teens who had recently been diagnosed with leukemia. He’d had a central line placed and had been started on the appropriate chemotherapy regimen. The hematology/oncology team did everything right. Then, just weeks into his treatment, Jonathan began to feel off. Within a couple of hours, his parents became concerned when he developed a high fever and felt woozy.
This room was filled with thick darkness. The floor team was already executing a choreographed somber march that, when I saw it, raised the hairs on my neck. Jonathan was already unconscious and in terrible shape when we arrived. During the admitting process for a fever and neutropenia, Jonathan crashed in front of the ward team. They immediately began aggressive supportive measures to stabilize his blood pressure, which was plummeting. He was receiving fluids and medications to support his cardiovascular system, and the team was preparing to intubate him so they could support his breathing mechanically.
As the ICU team, we took over care from the ward team almost immediately and decided to move him to the ICU, where we had more resources and a dedicated critical care team. Even as we moved him between floors, he began doing worse. By the time we reached the ICU, it was clear that this was going to be a long afternoon.
Alarms rang, lights flashed, and the rumble of many quiet voices filled the space and left no room for anything else. We were a full team. The PICU attending, several PICU fellows, respiratory therapists, and several ICU nurses were all working methodically to save Jonathan. My job as a resident in a room full of ICU specialists was pretty simple: jump in and help with CPR whenever needed and report any noted change in status immediately to the attending and fellows. All these things I did, and with round after round of CPR, the crunching of ribs and the squeak of a hospital bed frame with every compression created a dismal rhythm in my mind.
I wasn’t completely green. The team knew me from a previous rotation, so 20 minutes into the resuscitation, the attending physician asked me if I would go out to the waiting area to update the parents. This wasn’t new to me. Several years into a pediatric residency, I’d already had too many of these conversations with terrified parents. So I agreed.
My memory is vague at this point. I remember how young they looked to have a teenage child. They held hands, fingers interlocked and white from squeezing. I remember too that they were leaning forward on adjacent chairs, but more than that, they leaned on each other, head touching head. Now I think families are witnesses to the efforts undertaken to save their child, but back then, it wasn’t so common. They were alone, in a sterile family room, wondering. Knowing this, I tried to paint a picture of what was happening for their son. I began by explaining that Jonathan was in grave condition. I explained that his heart had stopped beating and that we were providing him chest compressions to help move oxygen to his brain, and to hopefully restart it. I talked about the breathing tube that we’d inserted into his airway to provide him with oxygen and to allow us to breathe for him. I explained that it appeared that Jonathan had developed a sudden, overwhelming infection and that it, and his body’s response, was causing his blood pressure to fall to dangerously low levels, and that we were treating that with antibiotics, supportive meds, and special fluids. Everything that I could think of, I tried to describe. I also told them that we were doing everything that we could do to help him, but his condition was so severe that we weren’t sure we could save him. It was all so…clinical.
After answering a couple of questions and sitting with them for a little bit. I excused myself and went back to the ICU. Jonathan’s picture was not improving at all. I jumped in for another round of chest compressions, and the team worked on him for another 15 or 20 minutes. It was becoming clear that we would not be able to save Jonathan. The attending asked me to speak to the family again, so I left to find them.
My second, and later third, conversations with the family went about the same as the first. I was somber and truthful; the situation was grave. Each time, I tried to gently warn them that things were not going well and that the outcome would likely not be a good one. I said all the things I needed to say, but none of the things I should have.
The attending called an end to the resuscitation and documented the time of death, a little more than an hour after we met Jonathan. Mom and Dad were invited in to see him and the evidence of our efforts to save him. Typically, the rooms were left largely as they were during the resuscitation efforts so that the parents could see the efforts taken to save their son, but the team cleaned any visible blood from Jonathan to avoid any undue trauma. Everything about this moment in their lives was undue trauma.
As is always the case, we moved on to other tasks, and soon thoughts of Jonathan were stowed into that memory box every physician opens quickly to store, but tries desperately to never open for any other reason.
I was forced to open that box nearly a year later when a letter arrived for me in the resident’s office. It was a nondescript-looking envelope, but inside was the message every physician dreads. Jonathan’s parents intended to sue me for the death of their child. I wanted to throw up as the world and the words spun around me.
I read and re-read the letter, sure it was intended for someone else. Realizing it wasn’t a mistake, I quickly moved from shock to anger. How could they blame me? I’d been so kind and supportive to them in their darkest hours. None of it made sense, and I grew to deeply resent them.
I spoke with our risk manager, and she reassured me that letters like this were meant to extend the time to file a lawsuit. She explained that they’d work hard to protect me and deflect any malpractice accusations away from me and toward the hospital. Still, my anger, likely fueled by the deep anxiety of it all, continued to simmer. How could they think I hurt their son? I was part of the team that tried desperately to save him! I didn’t give him his cancer, or his chemo that lowered his immune cells while it tried to fight the bad cells, or the infection that ravaged his young body. Poor me.
While no lawsuit was ever filed against me or the hospital, some 30 years later, thinking of Jonathan and the events of that afternoon still stirs high emotion in me, but it’s a very different feeling. Long gone are feelings of anger at Jonathan’s parents. As a dad, sitting in a coffee shop thinking about that experience, I’m simply filled with deep sadness for Jonathan’s parents. How often do thoughts of their little boy come to mind? Are they mostly happy memories now, or is it just more pain, perhaps dulled by the years?
Three decades later, I’m left with some tough new questions. What do you do with the knowledge that someone probably thinks you’re responsible for the death of their child? How do you manage the realization that somewhere, two parents, when they think of you, likely taste bile? I don’t know if I’ve found the right way to manage that knowledge. I don’t know if there is a “right” way.
Mostly, though, I think about missed opportunities to be a true physician in that moment. Sure, I said all the necessary words, but there were so many words that went unsaid. Words that maybe would have changed that moment from pure terror and absolute grief, into something that truly communicated how much we cared about the boy, and these two young parents. I don’t remember asking a single thing about Jonathan, the kid. Why didn’t I take a moment to ask what his favorite thing in the world was? Did he love to play soccer? Or baseball? Who was his best friend? What did they love to do together as a family before cancer made the world go dark? Why didn’t I try to heal them, even a little bit?
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Dear Jonathan,
We never met, really. You were already so sick when I first saw you. We tried everything we could to make you better, and I tried hard to make sure your mom and dad knew that. But I wish I’d done more to learn about you, to see the look in their eyes when they talk about you, their precious boy.
I’m sorry I wasn’t brave or present enough back then to know how important that would be for them, and for me. I want you to know, though, how much your parents love you. I could see in their eyes that they’d have given anything in the world to trade places with you that day. I’m certain that not a day goes by for them that they don’t think about you and feel nothing but pure love.
I know now that I could have done so much more, not with the practice of medicine, but as a human being for your mom and dad. What I wouldn’t give for the opportunity to go back in time and just give them a touch, or a hug, or even a word of genuine kindness. I’m so deeply sorry for this.
I hope more than anything, in spite of my human failings that day and the words unsaid, that their memories of you are by far the best ones, and that they bring more smiles than sadness.
Yours,
Dr. Chris