[This essay is the text of a 20-min talk I gave on this date at Medical Grand Rounds at Rochester (NY) General Hospital. The talk was one of three presented as part of the annual Humanities in Medicine series honoring Dr. Gary Wahl, a respected clinician who died in 2018 of pancreatic cancer at the age of 64.]
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Good morning, everyone. I realize, looking out on this audience, that I know hardly any of you, and at one time I would have known most of you. But even without that familiarity, I hope you can hear me out. Gary Wahl and I (and our families) had been friends since our fellowship. We went back pretty far. I am retired now, and he would have been also, had he lived. So it is truly an honor to share in this tradition of lectures in his memory. Thank you very much for this chance to speak from my heart on something of what it means to be a physician.
The following story has been important for me. It has had different interpretations depending on different phases of my life.
The story is from April 1994, when I was 40 years old. I had been an attending physician in pulmonary and critical care medicine for 8 years. I had put in my more than 10,000 hours as a resident; I had put in more than 20,000 hours as a fellow and junior attending. I had returned to Rochester four years previously after having tried and failed to succeed in a tenure-track position in New Haven. I returned here to be as good a clinician-teacher as I could be.
In 1994 I was the medical director of the MICU and chair of the RGH clinical ethics committee. Thus we were confronting and discussing the practical and ethical aspects of using prolonged life support. I would be the lead author in a soon to be published article in JAMA in which we described our experiences with withdrawing life support in 28 ICU cases.
Mrs. B was a patient in our MICU. She was the matriarch of a complicated family; she had long-standing interstitial lung disease even before being hospitalized; she was intubated and trached and had failed to wean from life support for the past 5 months. Palliative Care was not a specialty then, but part of what we did in the ICU.
She said she was tired of living on a ventilator. Her grown sons were split, split between the pain of “losing her” on the one hand and the pain of witnessing her breathlessness during CPAP trials, and her distress and precariousness during infections. Making it difficult to decide, as well, she was very comfortable and engaging in between those weaning trials and infections.
So she came to want to discontinue her ventilator, and her husband supported her decision. Her sons were resistant, but after some time, they were also able to be convinced that removing the ventilator and letting her die would be better for her than always living in an ICU, always on life-support, and always without any hope of going home.
On the morning of ventilator withdrawal, we gathered – family and ICU team members. I felt it important for me to be present to supervise the details. To provide comfort, we started a morphine drip and probably lorazepam (Ativan); propofol was not yet available; lorazepam (Versed) was not yet used regularly and was expensive. As she lapsed into unconsciousness, we performed CPAP trials to assess for breathlessness. That way, if her respirations got labored, we could give her boluses of meds and increase the drip rates. I probably gave her a hard pinch to assess her responsiveness to pain. Then when she seemed comfortable, not even responding to pain, we asked Respiratory to disconnect the ventilator tubing from the trach site and apply oxygen; we discontinued oximetry and other bedside monitoring. And then we waited for her to die peacefully.
Except … she didn’t!! She didn’t pass as expected.
After a few moments (I can’t remember how long), as her respirations maybe slowed and perhaps her color changed, she woke up – she suddenly WOKE UP!! She woke up, with a panicked look and heaving respirations. She became sweaty. What??!!
I turned to the nurse (here my recollection is incomplete): “Quick quick, Laura, get a syringe; draw up some morphine.” I looked at the nurse there with the syringe hooked up to the IV, and I took the syringe from Laura, and I pushed 10 mg of morphine, or maybe more.
The effects would not be immediate: it takes a minute or two for morphine to work; at least 5 or 10 min to achieve peak effects. Mrs. B was still labored, still diaphoretic. We were empty-handed as we held her hand and waited for the morphine to work. We increased the drip rate. I don’t remember how long it took for her breathing to slow down again and her diaphoresis to subside.
We probably left her to be with her family and went to the nurses’ station to watch her EKG, and when she lost cardiac activity (went flat line), we returned to perform the other rituals of pronouncing death: no pulse, no respirations, no heartbeat, fixed and dilated eyes; time of death ___. Thank you’s to the staff and family.
I was very shaken. I had to take a few moments by myself. It remains a memory of probably the hardest thing I have ever done in my life. WHAT did I just do???!
Intellectually, analytically, this was a perfect example of the Double Effect of an intervention. We intend to relieve suffering with the intervention, knowing (but maybe not really wanting to know) that death may be a consequence, a “side-effect.” But it is very rare, even in my line of work, to have such a stark example. It is rare to be in the room when it happens, pushing the meds when it happens.
One moment, the patient is suffering. Then we make an intentional action with possible or likely lethal effects. Then we stand empty-handed, waiting for our intentions to work. And then … the end of a life: something vital is gone; only the non-vital body remains. The transition from life to death was the action I took.
That case shook me. Please join me as I still try to make meaning out of this memory.
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First of all, the meaning of this for me does not need to be the meaning for you. Please use these facts, imagine yourselves there, and relate them to the other facts and relations in your worlds, your circumstances, your lives.
And I should also note, the meaning of this experience has changed for me – even as I prepared this reflection. It was a powerful event, very significant for me, and it provided me a sense of Purpose and Explanation for the rest of my career. Now, a little surprisingly for me, what I drew from it 30 years ago has changed, changed because my thoughts and my experiences have changed since retiring – since letting go of my professional persona.
And that, I think, could be and maybe should be the way for you also. I offer my opinions honestly and humbly. Please don’t accept them except as far as they can work for you. And please, you don’t have to draw “conclusions” that don’t change. “Closure” may feel necessary after difficult events, but closure can still be altered by reframing your perspectives.
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Clearly at the time, this was hard on me. But it was not guilt that made it hard, it was the burden of responsibility. I could readily rationalize the virtues of my decision-making: I was the attending physician, the ultimately responsible person; I was present; I did not delegate the act to others – not the nurse or the resident, and we didn’t have APPs then.
At the time I concluded – I generalized – that that was the necessary role of physicians: sometimes we must decide and act, even in the face of uncertainty, when action is required. That is the “burden of responsibility,” and you have to be practiced enough, tough enough to accept that. It is a worthy principle, a good axiom: “Physicians and providers are called to decide and to act.”
Furthermore, and I have rationalized this for a long time, when I was put in that position that day, one consequence of that action was that I took on some suffering and pain (some psychic pain) in order to spare others: to spare the nurse, spare the family, spare the patient. I believe (I truly believe) it is part of our role to do so.
One purpose in medicine, therefore, might be in fact to care for others’ suffering, even if it means taking on suffering ourselves. There is philosophical, sociological and anthropological support for such a view. Some have, and it is appropriate and wise to do so, some have labeled this the “priestly role” of physicians: we stand at thresholds between life and death; we are responsible for mediating between health and illness. And having been tested and trained and licensed to do so, we have to accept that responsibility and be accountable for our decisions.
So that is another worthy and sustaining principle to hold, one that I used and told myself: “We take on some suffering to help others.” It is something we can develop, share and teach in our professional identities. We have to learn to be strong, to be able to lend strength to others in their times of need.
But there are prices to pay.
Suffering is ubiquitous: there is so much physical and emotional pain in the world – and the pains are brought to, gathered in, heaped up in healthcare, particularly in the hospital.
Our mastery of ourselves in the face of struggles (our own and everyone else’s) will become a source of pride and self-worth. We engaged in a ton of self-denial and deferred gratification for 30 or 40 years of life: we started with some intellectual giftedness, worked hard, and successfully internalized parental and societal expectations – and we became doctors. You are no stranger to personal sacrifice; you are no stranger to overcoming barriers. This profession has taught you to carry on despite self-doubt and setbacks. For many years, that is the motivation for each day: survive the challenges that will show up.
In our work therefore, we rely on survival principles and attitudes. For instance, we can intellectualize that illnesses are biological challenges, ones for which we have drugs and other fixes. We try to maintain a dispassionate equanimity in the presence of grief and suffering – because we’ve seen it too many times. We learned to be strong, at first to survive, and ultimately, we could rationalize, to be able to lend strength to others in their need.
But … I also know (from my own experience) that such attitudes, which work so well professionally, can spill over too easily into one’s personal life. In particular, it became difficult for me (it’s still difficult) to feel someone else’s or even my own losses. Someone’s death or illness can seem like an event or a medical problem, something to analyze. Death and illness do not seem shocking or feel like calamities. They can feel like … information.
It is important not to carry one’s professional defenses into one’s personal life. It is possible to value not having solid defenses. You can, you perhaps should wish to feel hurt of losses in your personal lives. Don’t compartmentalize that much! It is not “bad” to feel grief, even though it can be painful and overwhelming. Passing through that, working through the processes of grief, will help you appreciate the experiences of others. It will add to your understanding of others.
So I hope that you can recall a time when you sobbed – and sobbed deeply: to have felt and not just acknowledged that a tragic event or loss had occurred. Because being able to sob would remind you that you are actually “normal.” We are meant to sob deeply when a loved one dies – someone perhaps who suffered far more agony than they deserved. Someone with such essential goodness that you still wish they were here, for they were such a light and comfort to so many. Someone who had clearly died before their time and who will not be sharing in the loves and pleasures we still have today.
When we get good at insulating ourselves against the grief of others, there is also unfortunately the danger of forgetting how to be vulnerable, or refusing to be vulnerable. We may forget or refuse to believe that there is joy and comfort in letting down our guards, to be vulnerable again.
Take it or leave it, I offer you this: When you suppress your ability to feel pain, you may also be suppressing your ability to feel joy and to be generous.
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So as I look back on that episode of 30 years ago, I am not as sure as I once was that it was “good for me.”
We were very good that day, technically and compassionately. If you’re a student or intern, it might seem awesome, that such mastery and kindness were possible and that someday those skills could be yours, too. We responded to Mrs. B’s needs very well. It was a touchstone experience for me, taking lessons that day that I lived by and which guided me from then on. Yes, it is good to take on the pain of others in our professionalism – to be strong and not weak: not only with our knowledge and skills, but strong and not weak in emotional steadiness and ethical awareness.
As a retired physician though, I confess that I am humbled to understand that those professional principles (“Be competent.” “Be strong and decisive because others depend on you”) can be inadequate or unnecessary, and even counterproductive in your non-professional lives.
How might we resolve this apparent paradox, without compartmentalizing our lives? What words might guide, sustain, and even inspire you in the grind you’re in and in your struggles to balance this professional training against the other parts of your lives?
I offer you this mantra to try, something besides, “Be strong and don’t be weak.” Try this to guide your patient care and your living, wonderful words I encountered relatively recently, in the last 10 years: “Know me, care for me, ease my way.”
With Mrs. B we were able to ease her way, with compassionate understanding and technical expertise, and as a team. But first of all it required familiarity with her and her family – to know and to see her and her family as unique and worthy of our understanding and support. It took wanting to know them for us (the whole team) to make caring and thus trustworthy decisions for her.
“Know me, care for me, ease my way.” That aphorism applies to yourselves also. So please: know yourselves, care for yourselves, be kind to yourselves.
Give yourselves time, time to get to know and care about your feelings and values – they are unique and worthy, too. Even while you are deferring gratification, try to find time to cultivate the generous, curious, and caring parts of yourselves.
When you know yourselves and take care of yourselves, you are building internal awareness and motivations: you are stabilizing the emotional and purposeful parts of your lives.
I think, I hope, I believe that that kind of self-care will give you a resilient strength to face your work, a better type of strength than following rules, practicing behaviors, or even achieving external rewards like grades, status and money. And, best of all, that kind of self-care works also for your personal relationships.
Yes, you live and work in a system that wishes you to be excellent automatons. But … it is human suffering that you are working with, and that calls for caring responses, responses that come best from a place of your own self-knowledge and self-caring
“Know me, care for me, ease my way.” Try that as a mantra.
And thank you for hearing me out.