January 14, 2016

A dying doctor's last day in the OR

Daily Briefing

    Editor's note: This popular story from the Daily Briefing's archives was republished on Nov. 8, 2019.

    In an excerpt from his posthumously published memoir, neurosurgeon Paul Kalanithi reflected on his last day in the OR.

    Download URMC's end-of-life conversation prompts

    Kalanithi, a former neurosurgical resident at Stanford University, died last March—two years after being diagnosed with Stage IV metastatic lung cancer. He was 37.

    When he was able, Kalanithi continued to practice medicine. But after reviewing one of his own CT scans at the end of a busy day at the hospital, Kalanithi found "a new tumor, large, filling my right middle lobe."

    "I was neither angry nor scared. It simply was," he wrote.  "It was a fact about the world, like the distance from the sun to the Earth."

    The next round of treatment would be, Kalanithi knew, "tougher to endure." He would be away from the operating table for weeks, "perhaps months, perhaps forever." But Kalanithi had already scheduled the next day's patients for surgery. "I planned on having one last day as a resident," he wrote.

    Last day in the OR

    Kalanithi's last day in the OR started like many others, with morning rounds to review new admissions, scans, and overnight events.

    By the time Kalanithi scrubbed in for the last surgery of the day, it hit him that this could potentially be his very last time entering the OR.

    "Suddenly, the moment felt enormous."

    The patient was in for spinal surgery. "He was an elderly man whose spine had degenerated," Kalanithi recalled, "compressing his nerve roots and causing severe pain."

    Kalanithi took his time, making sure even the corners of the patient's draping were sharp and neat.

    "I wanted this case to be perfect," Kalanithi said.

    Kalanithi's last case started to drain him. "My back was beginning to ache," he said.

    And just as the surgery was beginning to conclude, the attending resident poked a hole in a membrane surrounding the spinal cord. Repairing the wound would take another hour of surgery.

    "By the time we finished the repair and removed the compressive soft tissue," Kalanithi wrote, "my shoulders burned."

    But there was still one last thing to be done—suturing the skin. Kalanithi used nylon stitching to close the incision, because he believed that it resulted in lower infection rates. Even though most surgeons used staples, "we would do this one, this final closure, my way," he wrote.

    After he left the OR, Kalanithi gathered his belongings that "accumulated over seven years of work"—phone chargers, toothbrushes, snacks, extra sets of clothes, and more. Everything went with him, except his collection of neurosurgery books. He left those behind.

    "They'd be of more use here," he wrote.

    Later that night, after hanging up his white coat, Kalanithi called his co-resident to tell her he would not be coming in on Monday.

    "You know, I've been having this recurring nightmare that this day was coming," she responded. "I don't know how you did this for so long" (Kalanithi, New Yorker, 1/11).

    Next, get URMC's end-of-life conversation prompts

    When it comes to end-of-life care, most organizations struggle to meet patients' needs. In a recent poll, 87% of Americans age 65 and older said that they believe their doctor should discuss end-of-life issues with their patients; however, only 27% of those polled had actually discussed these issues with their doctor.

    Download URMC's conversation prompts to start improving end-of-life care for patients.

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