Suffering

I think one of the harder things to do is watch someone suffer. I'm not sure if it's because it causes us to suffer ourselves, or if it just brings up fears of ourselves being in that situation.

Recently I had a patient with a complicated cancer. She was at our hospice house for an extended time, but clearly began to lose her fight. In those rough days of her body's transition to dying, she had a lot of symptoms. She was nauseated constantly, with dry heaves frequently, and had pain with any type of movement. Despite all the pills, liquids or IV's that I suggested for her, she wanted nothing.

Nurses began to fret and suggest maybe I could do something about this refusal of medications. "She's just lying in there, suffering..." Suggestions ranged from placing a pain patch, to convincing her of the necessity for a subcutaneous site so that medications could be given, despite her refusal.

While the intentions were good, I had to step back a minute.

Who am I to decide for someone the way they should die? While most would think suffering was indicative of a 'bad' death, the reality is for some, this is exactly the way they want to go. The number one priority for me as a palliative care physician is not to treat someone the way I want to be treated, or the way YOU want them to be treated, but to treat them the way THEY want to be treated.

Although very difficult, I respected my patient enough to not cajole, convince, persuade or trick her into pain medicine. With every frown, moan or grimace I winced, but in allowing her to do things her way, I witnessed an amazing ability she had to stay present, in mind and spirit, till the last moments of her life.

She died smiling. Her journey may not have been my choice, but it needed to be hers.

Artificial flowers

Walking around work recently I noticed a sudden new addition of plastic flowers in some of the winter lorn gardens. They weren't hard to miss, bright pink and yellow, they were planted in both pots and soil in this one particular area.  I thought to myself it was a bit uncharacteristic of our neatly manicured flower beds. 

Later that day I met one of the pediatric patients I'm caring for. It's always tough to have a young kid with a terminal disease at the hospice house.  I learned however, that this is one incredible kid. He has been able to get up to a wheel chair from time to time and get out of the room.  It was on one of these outings that he crossed paths with the patient in the room next door.  The adult patient, having been pushed outside in her hospital bed, was heard lamenting that she may not be alive to see spring.

With that perfect sweetness that can come from a child, my little patient whispered to his parents, "We should get some flowers for her, so she'll be happy."

Thus, the fake flowers appeared.  I smile at them daily, not just because they are the precursors for spring, but as a reminder of my little patient... though dying himself, he is unselfish enough to think of another's happiness. 

Unforgettable

I had one of those unexplainable moments at work this week.

We had just admitted a little baby. He was born with so many birth defects, that the doctors had told the family there was nothing to be offered.  There were problems with his brain, his eyes, his mouth, his heart, his intestines were even formed on the outside of his body. Once the decision to focus on comfort was made, the breathing tube was removed and he was transferred to our hospice house.

Mom got here 1st with him. She was 20 something and overwhelmed. As I was meeting her and the little boy, I noticed some sudden breathing changes. His color was changing to more blue/grey and I realized the worst; this little baby was dying just minutes after getting here. 

We gently interrupted our process of admission to see if she wanted to hold her son, trying not to be alarming, but letting her know that her son's breathing was slowing and it looked like he was dying.  She cuddled him. I and the nurse hugged her from each side as we sat and cried.  The breathing was a pattern of long 40 sec. pauses with just a short little gasp/gulp in between.  I listened to his heart which had almost stopped, just an occasional out of sync little beat. 

If only his father was here, but he was still enroute. Mom prayed for more time...I prayed for more time, I think all of us were praying for more time. 

And then, something I have never seen.  That baby boy's color began to pink up. I listened again to the heart, confused at the color change, and as I listened that heart beat began again, strong and fast.  Simultaneously the breathing started again, quick and fast. 

Just like that, he was back, living and breathing.  The nurse and I were flabbergasted. She whispered to his mom, "You're son's spirit must be strong, he wasn't ready to go yet."  His mom wept anew, but this time with joy.

A little miracle.  I wish I could say he went on living, or that all those malformations were healed. But in truth his heart was much too weak. Instead, his father arrived a little later. The two of them, mom and dad, spent the next hours holding him and loving him, and then just as before, the breathing changed.  This time though, they were together as a family. They ushered him out of this world together, peacefully.

Best Christmas ever?

When I first met Mr. R, who had just been told that his heart was so weak, that he'd likely die within weeks, and asked him who I could contact for a family meeting, he told me "no one".  Of his 3 children, he was estranged from them all. I pitied him, he'd clearly chosen a life of solitude.  The event that prompted his admission to the hospital was being found by his neighbor on his floor of his home. He was extremely thin, having lost  60lbs of weight this year, he was very weak and he was having a hard time breathing.

I almost left it at that, accepting that there was no one he wanted to contact, but I pressed him a bit to see if there was a glimmer of hope. Finally he teared up and weakly said I could try his daughter on the east coast. I think he was more afraid of rejection than the hope of seeing his kids again.

A few days later his daughter arrived and the tears flowed as the power of forgiveness wafted over each of them.  "Can I call Teddy?" his daughter asked, speaking of one of his sons. He bristled as the mood changed and he grunted "No".Well I thought, at least he'd been reconnected with his daughter.

Mr R. left the hospital and I lost track of him until this week, when I started back at the hospice house.  When I walked into his room I was surprised to see a room full of people. Such a contrast from the lonely, sad man I had first encountered weeks before. I asked Mr. R to introduce me to everyone. He beamed with pride as he introduced grandchildren he had recently just met and then had to pause as tears started when he came to his son.  It had been 20 years since they'd talked.

These are precisely the moments I live for in palliative care. I was a witness to healing; not a physical kind of healing, because Mr. R is still in the process of dying, but a relational healing.

It's seems backwards to say, with Mr. R on his deathbed, that this will be the best Christmas ever for them - but strangely it is.

No one should...

I interacted with an incredible kid recently at the House. Innocent and respectful, he was not intimidated by authority and extremely kind to all he encountered.  I think this interaction sums it up: when meeting him at hospice with his mom, who was dying with cancer, he interrupted my solemn conversation to ask if we had any microwaves in the room to pop his marsh-mellow topped popcorn that he just couldn’t wait to eat.

As we interacted over the next days, I began to compile a list of things he’d gone through that seemed absolutely unfair.

No kid should have a mom be diagnosed with cancer
No kid should have to stay up all night walking her up and down their stairs at home, at least 20 times, because she’s too restless to know any better.
No kid should have to watch his mom swing at the air and shove people away from delirium
No kid should have to experience telling their mom “I love you” only to hear “I hate you” back with a blank unknowing stare; even if it is the liver failure causing her to be out of her mind.
No kid should have to wake up every hour of the night to look at the clock and wonder if his mother was still alive.
No kid should have to sit at the bedside of his dying mother, wondering why she made strange sounds, why her feet were blue and whether she could still hear him say “don’t go”.

I wish my list ended here. But tragically I must add:

No kid should go through all that, have a mother die, and then 36 hours later have his father die to. 

Universal

There's much debate ongoing in the healthcare-for-all arena these days. I won't weigh in politically, however, I'd like to share this story:

Kathy had a terrible childhood. You'd expect this if you had to watch your mother die of cancer when you were 8 years old. Kathy and her brothers got even more bad news as they grew. The cancer their mom had died with was inherited. Their family had a condition that put them at tremendous risk for getting the same cancer. It wasn't until Kathy's older brother was diagnosed and died at age 25 that the reality of this all sank in for her.

Kathy, a teenager when her brother died, made 2 related vows. She was not going to die of this cancer, and she was not ever going to leave children "motherless" like her own mom did. Still on her father's health insurance Kathy began the suggested annual screens needed to watch for this cancer.

Years went by and many things happened; Kathy got married, had 3 kids and then divorced. In her late 20's she found herself a single mom, working odd jobs to support her family, and no way to pay for her own health insurance. As they, say she was the working poor.

And what stopped? Those annual screens. Unlike clinics that offer free mammograms and blood tests, Kathy needed an invasive screen that no one provides "free".

In her 30's Kathy met Allen. They fell in love, married and quickly got pregnant. Kathy was delighted to again have health insurance through Allen and quickly made arrangements to begin the screening.

You will already know where this is headed. I can't imagine being told that I had cancer. For Kathy it was even more gut wrenching, she knew she would probably get it, and yet hadn't had the means to catch it early and possibly cure it. The vows she had made as a teenager would all be broken, and although Kathy fought through chemo and surgeries for 2 years, she did not win the fight. At the young age of 36, her life was over.

I met the new generation, the 11 year old, the 9 year old, the 6 year old who had her birthday 3 days before her mom died, and the little 2 year old. I wonder if they will be making vows themselves, and I wonder if they will live in a society with insurance that will allow them to put and end to their cancer cycle.

Borderline

If you have borderline personality disorder, please try really hard not to get an aggressive cancer.  The combination of the love/hate, push/pull personality doesn't do well with the rapid changes that come from say, ovarian cancer or pancreas cancer.

I recently took care of a woman in this situation. She'd opted not to pursue chemotherapy for her advanced cancer, but also seemed determined to feel good despite not wanting any medications.  Our daily conversations went something like this:

"Ms. Fraz, how are you this morning?"

"Miserable. Horrible. Awful", she’d say with her disheveled hair, eyes half open, and wrinkles cemented on her face from constant frowning.

"Oh?" Feigning surprise, though this was the 4th day in a row she'd said this, "What specifically is bothering you?"

"I'm vomiting, I'm in pain, and I'm so tired" were her general complaints.

To this I reminded her, "You know, Ms. Fraz, you haven't allowed us to give you any medication to help"

Her reply in full whine now, "But I don't like how medicine makes me feel" pause, "What are you going to do to fix me?"

And this is the crux of such a personality. She wanted someone else to fix her and to bare responsibility for her misfortune.

What makes borderline’s even more difficult in terminal illness is that they usually don’t have a lot of healthy relational support. 

Ms. Fraz, in fact, had only one single person as her friend. No family…no other human relation. More tragic, the one friend she did have, Bill, was adamantly apposed to her decision not to pursue chemotherapy.  He would tell her daily that she would be going to Hell for not trying to cure herself. “It’s like suicide to not try for a cure”.  He’d badger and bemoan her and she’d cry and get distressed. She’d demand he leave, and then call him back for more.

She was aware that when she lost the ability to make decisions herself, he would be in charge. She had given him that power legally, even acknowledging that he would probably choose things she didn’t want.

And so she spent her time dying of cancer, wanting to feel better, but refusing the help we offered. It was in this pitiful state of inertia that she continued to pull Bill in, to listen to his rants about her mistakes and damnation until finally she weakened and he won. Back to the hospital she went from hospice, to spend her last days hooked up to machines and IV’s, getting poked and prodded, pushed and pulled.  A perfect borderline personality metaphor; dying in the same way she lived.