Mar 21, 2012

End of Life Care: Does it ever get easier?

May 9, 2011 was the first day of my third year of medical school, first day on the cardiology inpatient service, and the first day I met Ms. W, my first patient. Ms. W was a 77 year old woman with COPD, right-sided heart failure, pulmonary hypertension, and was in the ICU for ARDS due to spontaneous hemorrhage of unknown etiology. Because taking care of Ms. W would be challenging and overwhelming, my senior resident and I walked into Ms. W’s room together for introductions.

I naively expected to see a charming elderly lady who was just a little short of breath. However, one could argue that formal introductions were not needed because Ms. W likely never even knew we had walked into her room—she was on a ventilator and thus was heavily sedated. Nevertheless, Ms. W was very much present. Her gray hair was pulled back in a high loose ponytail, her hands were warm and her head bobbed up and down with each breath. She would inconsistently raise her eyebrows at the sound of her name and her tongue would slide towards whichever side her body was turned on. Despite the lack of any form of acknowledgment at our first meeting, Ms. W made a significant impression on me because just fifteen years earlier, my grandmother, who was 77 years old, was also in the ICU heavily sedated and dependent on a ventilator.

I worked diligently to take care of Ms. W. Every morning, I cheerfully greeted her, carefully checked her heart and lung sounds, confirmed the presence or absence of distal pulses, monitored the position of her endotracheal tube, checked every inch of her skin for signs of rash or pressure ulcer, and recorded her ventilator settings. As part of my morning ritual, I crossed my fingers before picking up her record book of ventilator settings hoping to see a positive trend towards recovery over time. I zealously poured over books and primary literature to understand the complicated management of her cardiac, respiratory, and renal disturbances. Perhaps it was selfishly motivated, but I felt committed to Ms. W. I strongly believed that if I could heal Ms. W, I could make up for my lack of understanding and inability to help my grandmother fifteen years earlier.

As the days passed, there were no signs of improvement and there were plenty of subtle hints that even a modest amount of recovery was unlikely. Managing her fluid status with changes in either direction only made things worse. Family meetings were initiated. I stood in the shadows as difficult conversations uncovered internal family tensions between honoring Ms. W’s understood wishes and managing Mr. W’s feelings of loss. With each passing day left without a decision about our next steps, Ms. W steadily and slowly declined. Her ventilator settings started to uptick towards the need for more aggressive support, her kidney function was slipping, and the color of her feet became mottled. It was finally decided that it was time to let Ms. W go. Because Ms. W was my very first patient, my senior resident insisted that I join the family as they said good-bye.

The family, hospital chaplain, senior resident, and I all gathered into Ms. W’s room. Slowly, one by one, the beeping and whirring of the machines helping Ms. W stay alive were shut off. The endotracheal tube was removed and the only sounds left were short exhales of air and muffled sobs from Ms. W’s family. The sight of Ms. W’s family quietly and lovingly saying good-bye to her instantly transported me back to my grandmother’s hospital bed. Without consciously being aware of my own thoughts, I too began to sob as little bits and pieces of the past and present intermingled. I was not there when my grandmother passed away. But, simply transposing my father and mother’s faces onto Ms. W’s daughters felt all too real.

In just moments, after a few sputtering coughs, Ms. W stopped breathing. As I stood alone in my corner of the room shifting in and out of my own thoughts, I remembered that it was my father’s birthday--an overwhelming coincidence that made things too personal. With this realization, I said my good-byes to Ms. W and her family and then stepped out of the room rushing to find some privacy. All of the bathrooms were occupied, so I dashed into an empty family waiting room. I closed the door. I grabbed a box of tissues in one hand and held onto my cell phone with the other as I began to cry and wail. While I rationally and clinically understood the importance of discontinuing aggressive treatment for Ms. W, I could not resist feeling like I had failed her, and by association, failed my grandmother.

After gathering some composure, I loosened my grip on my cell phone and called my mother. She was away in China, but I ignored the inconvenient time difference because I needed to hear her warm and comforting voice. She explained and described how hard it was for us to let go of my grandmother. My mother assured me that it was the right thing to do and it was not a failure. My grandmother never wanted to be in the ICU and we had already disrespected those wishes for 200 days. She was ready and as honorable children, my parents had to let her go. Hearing the words that I myself have advocated for in regards to end of life care while working in the area of quality improvement of health care delivery, I calmed down and regained my strength.

My month on cardiology was only the beginning of a year of dramatic change and growth. By the end of my cardiology month, my clinical knowledge had increased exponentially. But, I can’t confidently say that I achieved similar emotional maturity. Ms. W was only the first of a total of four patients I lost that month (I have since lost another three while on surgery and lost my dog whom I was medically managing remotely as she succumbed to mesothelioma). On one hand, I have learned to harden my heart, for self-protection reasons, as I have not shed another tear for my patients. But, on the other hand, my great exposure to death has not made leaving the hospital when I had an unstable patient or losing patients any easier. Of all of my patients, the faces and narratives of the patients I have lost are those that I remember most vividly. The clinical courses and what I could have done differently, to some extent, haunt me. Consequently, the feelings of failure are always hovering and have shaped all of my future difficult patient experiences. Selfishly, I am drawn to more aggressive and alternative treatments despite promised or lack of promised outcomes.

Will my beliefs and instinctual emotions ever align? As I continue in my training, perhaps I will achieve a better balance between the science of medicine and the humanistic relationships with my patients enough to step away from my own selfish discomfort with failure. Will more experience become the evidence I can depend upon when making future clinical decisions? Because death and dying are fundamental aspects of medicine, for the sake of my patients and my own well-being, I certainly do hope that time and experience will foster the strength to be my patients’ guide through difficult times. Of all things, this is the best medicine that I can provide.

Mar 19, 2012

Remembering the Match Day Madness

Joshua Liao, BA, BS
Editor’s note: Joshua Liao, a fourth year medical student at Baylor College of Medicine, participated in Match Day this past Friday, where he found out that he will begin his Internal Medicine Residency this July at Brigham & Women’s Hospital in Boston, MA.
Most students have heard about the raw emotions—from elation to disappointment to contentment—on display during Match Day. As several leaders shared remarks in the minutes before envelopes were passed out last Friday, this became absolutely true for me. I felt the nervousness rising inside my chest, and I couldn’t take my eyes off the Match Board, the enormous vehicle my school uses for “job notification.” At Baylor, each student’s name is printed on the board with a corresponding envelope stapled beneath. The board is then covered by wrapping paper and parked behind the speakers until the appointed time.
Eventually, the envelopes were unveiled, and the seconds after I opened mine were a blur. I remember clenching my fist in gratitude before my loved ones mobbed me with congratulations. Behind me, shouts of joy mixed with epic, celebratory music. On the outside, I sensed my lips drawing into a wide, irresistible grin. Inside, I was absolutely ecstatic. I had matched into an absolutely amazing internal medicine residency.
After percolating in the feeling for several moments, I phoned my parents (who live in China) and then moved into the courtyard, congratulating my classmates and seeking out key mentors to thank them for their help and encouragement. Photos were taken, but I forget how many. There were many more hugs and handshakes. By the end of the event, I was exhausted and content.
Now, even just days after the Match festivities, I am struck by several important lessons about the whole process:
First, the moment can pass quickly. Plenty of people warned me about the intense emotions, but none told me how rapidly the whole thing would move. It felt like only seconds between the speeches and the paper being torn away from the board. I moved through the crowd to the board and removed my envelope, all without fully realizing it was happening. Seconds later, I was hugging my friends and family, and the uncertainty and nervousness had suddenly given way to relief and joy. The moment was like the first seconds after a dive into a cold pool; I felt the weight of my own feelings before I even realized them.
Second, the event can be as much the reinforcement of the past as it is the beginning of the future. Most know and think of Match Day as the beginning of new chapters in our lives, and in many ways, they are right. But as I embraced, laughed, and exchanged the good news with classmates, I realized how the moment seemed to strengthen my feelings toward them and my desire to stay in close touch going forward. Along my path around the courtyard, I ran into friends with whom I’d shared long study sessions, call nights, difficult cases, and extracurricular activities. I was able to enjoy a few moments with my closest friends from my medical school class. I found myself not only congratulating many of them, but also hoping sincerely that we would continue to stay in touch—in person, for those who’d be in the same city as me; via regular phone or webchat meetings for the others. Ultimately, I knew well in advance that Match Day would be a time to look ahead to residency. But I didn’t know it would stir such a strong sense of camaraderie and the desire to intentionally preserve my meaningful medical school friendships through demanding residency schedules. The thought felt warm against my chest.
Third, and most importantly, Match Day can be a powerful reminder of all the friends, family, and mentors who helped shape us. Some say that no man is an island, and that idea was never truer for me than during Friday’s celebrations. The notification paper only listed my name and the program’s name, but I remembered all the thoughtful letters of recommendation, advice, and input that contributed to that pairing. Several loved ones, friends, and mentors were present, and I was able to look them in the eyes and share from my deep gratitude. I owe long, thankful phone calls or letters to those who were not in attendance. Regardless, they were all in my thoughts almost immediately after I opened my envelope, where they have continued to linger in the hours and days following.
So for now, I will bask in the moment, thankful for the supporters and friends who journeyed through medical school with me. I will replay the moment from Match Day in my mind a few more times, to remember the anticipation and aftermath of it. But after a few days of this, I must stop. I have many letters of appreciation to write.
Where did you get matched? Leave a comment below and let us know where you’ll be starting your residency.