Each chest compression led to a larger and larger amount of blood shooting from the endotracheal tube like a hose whose kink had just been undone. The patient, a middle-aged woman, had been having chest pain for a number of days but was too busy taking care of her family to worry to much about it. Unfortunately the pain she felt was her grafted innominate artery eroding into her trachea. When this erosion was complete she began quickly and unstoppably bleeding into her own airway. By the time she got to me in the the trauma bay she had lost pulses and the Aeromed crew was coding her. An injury so devastating that had she collapsed outside the operating room door, I still don’t think we could have saved her. This, of course, is not something you can tell the family. Waiting in the other room, a husband and a mother waiting for news. Wanting so deeply to have me tell them that their loved one would be fine. That they would be able to go home, and have their wife and their daughter back. I love giving that news. “Everything is going to be OK,” I would say. “She has a long road ahead of her, but she will make a full recovery.” Not today, not this time.

As I walk into the cramped room I can feel the emotion thick in the air. I sit before speaking. I look up directly into the eyes of her husband. Beginning by introducing myself I try not to hurry my words. The prudent thing is not to rush into this. My next words will exist for this family forever. Calmly, compassionately, and with a soft tone I stare into this man’s eyes and say “When your wife came to us, she was very sick. I suspect she began to bleed from one of the arteries in her neck into her airway. I am sorry, but despite everything that we have done, she is gone.”

It isn’t always what you would expect, giving news like this. People aren’t always overcome with emotion, they don’t fall to the floor and cry, they don’t run screaming from the room. Without breaking eye contact, I pause. I try to let the weight of my words sink in. I can see the grief in his eyes, I can hear it in his voice. He asks one question. All that has transpired in the previous hours has been boiled down to one single question. “Did she suffer?” This is a critical moment, there are no second chances here. The slightest stutter or hesitation will color this man’s memories of this event permanently. In a deeper, more forceful tone, I respond “No.” No explanation, no details. Simply a “no.” An answer that can’t be dwelled on, that can’t be turned over and analyzed. A clear and unequivocal answer to put him at peace.

Finding the words is always difficult. There is no template that can simply be followed. Each family needs something different. At times, there will be families who want to know everything, every detail about what was done and what was found. But others, who are sitting in the room, will not want to hear any of it. This is a fine line to walk. All while trying to show compassion and respect for this time, for these people.

The words chosen can not be overly medical, but also must not be so vague as to cause confusion. The delivery has to be smooth and above all you must be very clear that the patient has died.

I am always overwhelmed with a fear that I will say the wrong thing or that the family will react in the extremes. After 4 years of medical school and 5 years of residency there are many things one will learn.

Leaving the room I am struck by a thought. Fleeting but ever present on my mind any time I have to do this complex part of my work. How do I teach this to junior residents? How do we learn this as a field? The question lies in not what do we teach, but a more difficult question of what can be taught? The act of compassion in all its subtleties is not found within lesson plans or classrooms.