Category Archives: spirituality

A Psychiatrist Waits for His Ten O’clock Patient and Imagines He Is Han Shan

 

–Richard M. Berlin

Daughter gone,

hair gone, my father

dead for half my life.

Patients I saved from suicide

lived until old age,

died from cancer instead!

Twenty years of hospital work.

Twenty years pruning apple trees

on the west flank of Cold Mountain.

Once they were sticks.

Now the branches bow with ripe fruit.

A faint wind stirs them.

I’ll share a bushel with the crows,

another with the worms!

 

 (Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

Dr. Berlin, a psychiatirst and poet whose poems we've shared in other blog entries, reflects on life's rhythms and transience mimicking the Chinese poet Han Shan. Han Shan referred to himself as Cold Mountain. Dr. Berlin lives on Cold Moutain. Han Shan was a cynic and a hermit who liked to poke fun at the self-importance of the other monks. Enjoy this brief reflection on all we try to do and hope to do as healers/physicians and what it all amounts too.

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End of life decisions–becoming your grandfather’s physician in rural Tennessee

–David McRay
Dr. McRay tells the story of helping his grandfather decide to end dialysis and agreed to be his physician so he could die at home. ..

As his creatinine level rose, his hematocrit fell, he had no choice. With the itching worse and the fatigue incapacitating, if he wanted to feel better—in fact, if he wanted to continue to live—he needed to begin dialysis. He did not understand what was being offered, how it would work or how it would make him feel. The therapy was never described as a form of life support
with all the customary conversations about indications, alternatives, ethics, and options for withdrawal. It was simply the next step in the management of his illness; a step he felt forced to accept but never really did.

The nearest dialysis center was in a town forty-five minutes north. Three days a week, my grandparents would leave home early in the morning and make the trip to greet the staff and submit to “misery,” the word he used to describe the way dialysis made him feel. Miserable though he was, he made the best of the situation, as he had always done with every hardship he encountered in his life and for two and a half years, he drove himself to dialysis most of the time.

A stroke changed everything. He awoke that morning with some troubling weakness and numbness in his right arm and leg. An ambulance trip and brief evaluation in the local hospital emergency room were followed by a transfer to the major medical center in Nashville where my grandfather remained hospitalized for two weeks. He was discharged to a rehabilitation hospital and then an extended care facility. He never suffered from a severe loss of function, but he became dependent, unable to attend to his most basic needs. His dignity was under attack; his spirit broken.

When his wife of sixty-one years passed away in her sleep, he asked, “What will happen if I don’t go back to dialysis?”

“I don’t know” was the only answer I could provide. I had never encountered this circumstance before. I knew he could delay his treatment a day, maybe two. A few days later, I spoke with a nephrologist in my community. She seemed very uncomfortable with the conversation and described the difficult deaths of two patients who chose to stop dialysis during her fellowship. Beyond that she offered little.

Granddad approached this decision in his usual careful and thoughtful manner. We continued our conversation and I tried to answer his many questions. We referenced the Christian Scriptures, talked about his relationship with God, and spoke of the confidence with which he felt he could approach the end of his life. We discussed other situations in which patients make decisions to withdraw life-sustaining medical care such as mechanical ventilation and tube feedings. He concluded that for him discontinuing renal dialysis was similar to discontinuing mechanical ventilation in the face of an irreversible, terminal illness. His kidneys had failed and would not recover. His life was without joy and now devoid of the experiences that had given it rich meaning for almost eight decades. Existence was limited to restless sleep on the bed or the sofa with painful, exhausting, and embarrassing trips to the bathroom.

Dr. McRay’s grandfather was enrolled in hospice and Dr. McRay agreed to become his grandfather’s physician so he could die at home. ..

The morphine and the hypoxia-induced sleep kept him unaware of the fluid that was filling his lungs. “I’m ready. Let’s go home,” were his final words. He slept and did not arouse again. His son held one hand and his daughter the other. I moved across the room and sat in a chair, watching with quiet reverence. This location provided my parents, aunt, and uncle enough space to be at his side. Perhaps the move was symbolic as well. My grandfather was dying on the couch, but he was also my patient. I needed to maintain some space, to hold on to the equinimitas I had found. Until my task was completed, I wanted and needed to protect my objectivity.

The end came quietly. Some of those present had never witnessed a death before. Startled, they looked to me for an interpretation, a diagnosis, a verdict. My solemn nod unlocked the door to their grief. Together we—his family and friends, his church and community, and me as his grandson and physician— allowed my grandfather to go home and stay home. With grace and courage, he overcame the obstacles presented by the rural location where he lived. With
hesitation and gratitude and with some sense of urgency and necessity, I overcame my uncertainty about the dual roles I was asked to play. I was honored and humbled by the privilege of helping my grandfather write the final chapter of his story. I believe he wrote it well.

Dr. McRay explores a number of important issues: ending life sustaining treatment such as dialysis, managing the dual roles—grandson and physician, the value of religion in exploring the big questions in life. In today’s world technology creates benefits and burdens. We can extend life, but those days and months are sometime more quantity than quality. Dr. McRay helped his grandfather decide to quit dialysis. Have you witnessed or been part of such discussions and decisions with patients? What did you learn? What will you take away from this essay as you help patients explore how they want to die and make decisions about resuscitation, intubation and advanced directives? How is religion and spirituality helpful to patients who have a faith?
Dr. McRay negotiates his dual role more carefully; this is explored more fully in part of this essay that is not included in the blog. What are important considerations for managing the dual roles?

Published in The Country Doctor Revisited (Kent State University Press, 2010) used with the permission of the author

Mashkikiwinini

Thanking Sylvester for His Unconditional Smile

–Arne Vainio

Sometimes teaching comes when you aren’t looking for it or even have the

time to think about it. Recently, one of my partners at Min-No-Aya-Win Human

Services Clinic on the Fond du Lac Ojibwe Reservation in Cloquet, Minnesota,

was off, and I saw one of her patients. Behind and rushed (as usual), I went over

Sylvester’s records enough to know he had metastatic cancer, but his records

were sketchy and I didn’t know much beyond that. Before I went in, one of the

nurses commented that she thought he was in denial about his prognosis. That’s

the expectation I had as I walked into Sylvester’s room and introduced myself. I

expected to see a man desperately holding out for a cure and a miracle. Instead,

I met a smiling man who welcomed me into the room. His eyes were bright and

clear, his smile sincere and real. In spite of that, he was pale, gaunt, and clearly

sick. He had dark circles under his eyes and his words came in short, labored

sentences. His belly was huge, even under his baggy shirt. He was short of breath

just sitting on the exam table.

 

“I would like to know if my cancer is worse. Last year I was told I had five

months to live. This year I’m going to plant tomatoes.” He had no illusions about

his cancer and his prognosis; he knew this was a bad cancer and was spreading.

In the room, I went through his records again and found a CT scan report

from six months earlier from a different medical system. The report stated “interval

worsening” since his last study, with spread of cancer to multiple areas

of his liver, into his abdominal wall muscles, and into the mesenteric area. His

cancer was a GIST (gastrointestinal stromal tumor), which is a rare cancer. It

can either be slow growing or aggressive. Unfortunately, his was very bad and

spreading rapidly. The fact that he had already asked not to be resuscitated was

in his records. There wasn’t much to do at this point except to make sure he was

comfortable and didn’t suffer.

 

He lifted his shirt and I could see the massive tumor under the

skin on the entire right side of his belly. It was tented up at an unnatural angle

and as hard as wood. As I felt around the edges of the tumor, I could feel that

it went deep inside his abdomen and I could feel other smaller tumors.

Sometimes diseases that involve the liver cause ascites, fluid collecting inside

the abdominal cavity. I could not identify this on exam but was hoping for it,

as draining it could help his breathing. A chest X-ray showed part of one of his

ribs eaten away and a mass inside his chest. He accepted this without complaint.

Through all of this, he was smiling and planning his garden.

Dr. Vainio reflects on the lessons that come from our patients. Clinics are busy and we often see patients on a tight schedule. It is easy to be moving so fast that we don’t take the time to get to know patients and learn about their lives and hopes. What lessons did Sylvester have to teach Dr. Vainio? What can we do to help patients end their lives as peacefully and painlessly as possible? Why was Sylvester focusing on his garden and tomatoes?

 

 

LIFEprayerDEATH

–Kathleen Farah

“I prayed for you”

she said.

“I prayed every day you would have a healthy baby.”

I did.

She sat across the aisle from me at church you know,

Exchanged greetings of peace and watched my pregnant belly grow.

We prayed.

Tall in my white coat I stood before her in shivering snowflake gown.

My eyes and hands observed the tumor her right arm birthed had grown.

I sighed.

Too few weeks later I kneel beside her in her home hospice bed.

“I pray for you”

I silently said.

Words and tears are blocked by “professional boundaries” in my head.

I silently cried.

“I pray you have a peaceful death.”

She did.

Dr. Farah explores professional boundaries, prayer and expressing emotions with patients. As we have explored in other posts (Onime) dual relationships are common in rural areas. Our patients are our friends, and expect to be. We may see them at church and at the grocery store. Close relationships increase compassion, but may also bias us in our care for patients. Being close to a patient may make us more compassionate in giving bad news, but may make it harder to help a patient make decisions about their care because we have our own opinions and hopes as their friend.   What have you seen on your rural rotations?

Dr. Farah also explores expressing emotions with patients. Crying with and for a patient is not a bad thing as long as we can step back and be in our doctor role when we need to be. The ability to move from one role to another is often called compartmentalizing. This allows us to switch between roles. For example, in a crisis, I need to put my feelings aside so I can think clearly and make decisions about what to do. Feeling sadness or happiness for and with patients is also quite human and shows that we care. Grieving the loss of a patient we were close to is normal and healthy.  As a physician we are privileged to walk through the best and worst of times with patients. It is important to learn how to distance ourselves from some of the intense emotions, otherwise the roller-coaster ride of highs and lows is exhausting and draining. However, not taking the time to feel the feelings at all can lead to cynicism and burnout.