What is an ending? Strictly defined, an ending is the “final part of something, especially a period of time, an activity, or a story.”
Endings riddle our work as emergency physicians. We confront mortality and the limits of the body and mind on a daily basis, and yet, rarely do we stop to examine and reflect upon the emotional dimensions of these profound experiences. Emergency medicine teaches us again and again that endings are rarely fixed and have a way of challenging our expectations. Obvious examples include the cardiac arrest victim whose pulse returns just when we’re about to announce a time of death or that critically ill patient who always seems to roll in at the exact moment we believe our shift will end on time.
Obviously, certain endings are measured by time. Death as an end to life, the end of a shift, and even the waning light of our careers. In fact, within our careers, we come to anticipate endings as part of our growth, the end of medical school, the end of emergency medicine training, as examples. These types of endings are no less meaningful, often injected with uncertainty and trepidation as we meet the changes in self-identity and in our relationships, proving that time alone does not give endings their measure.
Just as there are different types of endings, the endings themselves may resonate in different ways. When patients die, we may mourn the loss of a person’s life. But we may also be equally impacted by this person’s web of relationships, and the impact of this loss on their lives. We might ache over our decisions in their care, and what, if anything, we might have done differently to save them, or how the situation reflects on us as caregivers.
As we draw off of our experiences with diseases and diagnoses, we allow our previous experiences with endings to shape our communications of diagnoses that may be life-changing or life-endings. We come to appreciate and understand the impact of our words in these moments, words that may be “seasoned” with prior endings, that unexpectedly give birth to new found sympathies and new practice patterns. In this way, endings may even become transitions.
Of course, through all of our careers, there are happy endings, too. Patients who come to us with a problem, who receive treatment, and then return to their former selves. The sociologist Arthur Frank refers to this as a “restitution narrative.” Unfortunately, we have a tendency to focus our attention on cases that have gone wrong and are less inclined to examine and celebrate our happy endings.
Uniquely common to the specialty of emergency medicine, the absence of an ending can be a source of frustration. Once patients leave us, their fate is often left to our imagination, keeping us awake at night. And, in fact, lack of closure specific to emergency medicine practice can be a source of discomfort, but we can’t ignore the uncertainty that pervades medicine as a whole. In that vein, we must be cautious that our appetite for stories that have coherence and have endings does not lead to cognitive errors by unconsciously creating coherent narratives when none exist.
If we’re fortunate, endings will carve new paths and promote new understanding of ourselves, our work, and our relationships. Perhaps they were never truly endings in the first place, but the start of new beginnings.