Time of death: unknown. It was around 6 p.m. on April 21, 2013. My mom saw my grandfather dying slowly in the hospital bed. She had pressed the nurse call button frantically over the last 20 minutes. She rushed to the nurse station only to find out nobody was there. She went back to my grandfather and spent the last three minutes with him. She was the one who saw my grandfather’s bpm (beats per minute) dropping from 50 … 40 … 30 … 20 … 10 … to 0. She was the one who could pronounce the exact time of death. Not nurses. Not physicians. When my mom was holding my grandfather’s hand and looking at the heart monitor, I was in Ann Arbor, MI. Graduation was ten days away. I was studying for calculus II, my last final exam that was coming up in two days. When I heard the news, I went numb. I didn’t cry. I couldn’t cry. Didn’t feel anything. Couldn’t feel anything. Just numb. I finished my exam, returned to my room, and sat there for the next few days until I flew back to Japan. If only the resident physician was paying enough attention to notice his fluctuating blood pressure on that day. If only he was humble enough to ask his attending physician for advice. If only he cared more. If only the heart monitor my grandfather was hooked up to was not turned off at the nurse station. Those who know about medical errors and patient safety would bring up terms like the “Swiss Cheese Model” and authority gradient to explain what happened to my grandfather. I know that medical errors have different types, like slips and cognitive errors. I know how errors are often the consequence of organizational failure instead of an individual. But when you lose someone like this, none of these matters. It’s done. The person is gone. The person never comes back. I’m not criticizing this physician for making an error. People make mistakes, and so do physicians. What matters is how you deal with those mistakes. The attending physician refused to let my mom talk to the resident because he was concerned that the conversation would ruin the new physician’s confidence and his future. Refusing to admit your lapse is a pathetic way to run away from the reality that you messed up. When our loved one dies, family members just want the truth. When physicians make mistakes, all we want are the simple words, “I am sorry.” So, dear health care providers: Talk to us. Tell us what’s on your mind as though you’re talking to your friends. Tell us what you are unsure about. Tell us what you fear. Say “I’m sorry” if you made mistakes. We will not sue you just because you made mistakes. When you cover up what happened, we feel betrayed, disappointed, angry, and hurt. All we want is a true story. And to anyone whose loved ones are at a hospital: Fight for your loved ones. Fight for yourself. Share what you fear. Ask questions. Ask your health care providers to share what they are unsure about. Ask them what they fear. At the end of the day, you and health care providers want the same thing: To save human lives one at a time. Source
