Monday, August 11, 2008

Palliative Care

This post is about a patient, approximately my age, whom I visited at the hospital last year. As usual, names and other details have been changed.

The first thing that I noticed about Maria, was not the oxygen mask into which that she desperately breathed, nor the black and blue marks that whirled along her arms ( inflicted by needles, syringes, and other abusive medical equipment), but her carefully painted fingernails. This was clearly a woman whose family lavished attention upon her. We said hello to 28-year-old Maria, who recognized us with her eyes, but could not respond due to the breast cancer, that had metastasized to her brain, bones and liver. As late as yesterday, Maria was able to express that her pain was a “9 out of 10." Today, she just stared at us intensely.

Dr. Stone, who heads the palliative care office at our hospital, felt that it was perhaps time to discuss with the family about increasing the pain medication, and about how the exhaustive poking, prodding, and procedures, should now be reconsidered. She wanted to explain that Maria could perhaps spend her last days without suffering, and with her family by her side.

Surrounding Maria’s bed were pictures of her as a little girl, as well as of the Virgin Mary, and other Catholic Saints. Taped onto Maria’s bedpost was an image of Jesus, toward which I imagined Maria used to pray, long before the drugs diminished her comprehension. Dr. Stone recommended to Maria’s sisters that there be a family meeting with Father Joe, the hospital’s priest. Instantly, Maria’s sisters felt comforted by the idea. They weren’t as religious as they had been growing up, but they knew that their mother, who was grieving in the lobby, would be happy that a pastor could be present, to console them and help them make decisions during this agonizing time.

I knew that Maria’s sisters would remember every detail of this day forever. I came to this understanding because of the experience that morning in Dr. Stone’s office, when each member of our six-member clinical medicine group went through his and her own experiences dealing with death and loss. Even though it was about the fourth time I had heard each person’s personal story, I found that each retelling provided new details and perspectives. Experiencing the last days of a loved one’s life means that little things begin to take on great importance. Do we take her to the bathroom now or later? Should we give her more pain medication? Does she want to be propped up higher on her bed? These seemingly minor concerns can drive families into tortuous doubt and bitter conflict.

This is why I was most impressed with Dr. Stone’s explanation that palliative care was as much for the patient’s families as for the patients’ themselves. Families are given the opportunity to lay on the couch, talk things over with the palliative care staff, and to drink tea in the office upstairs. The program itself allows them to gain reprieve from nurses who visit the home once a day, an opportunity which does not cost the families extra money. If possible, patients and their loved ones have the opportunity to spend the patient’s last days in their home, rather than in a stale, impersonal hospital ward.

That day in the hospital, I saw Maria’s sister, Carmella express denial that her sister was truly going to die soon, hoping she could “stay alive just until after Thanksgiving.” She was angry, saying her death didn’t make sense because “Maria was the smallest of the three sisters.” Carmella bargained with the doctors about attempting other life-extending measures, if not a whole new round of chemotherapy. Ultimately, she started to feel depressed, realizing by the end that Maria's imminent death was inevitable. However, as Dr. Stone, the nurses, and we students gave Carmella hugs, stroked her tears, and stood with her in silence, she began the process of acceptance, breathing easier, returning our hugs, and realizing how her dear sister could live her final days at greater ease, surrounded by the people who love her.

No comments: