Friday, January 04, 2019

This and Then That

I visited a patient in the ICU who was moaning and writhing; she mumbled that she was in “excruciating” pain. Her nurse observed that the liver and pancreas work closely together, so if one is impaired, the other may be, too. Apparently pancreas problems are painful, and liver problems, as I know from personal experience with mono-related hepatitis, can cause dreadful thirst, among other things. However, drinking water exacerbates the pain in the pancreas (I hope this analysis is semi-correct), and while I was charting, I could hear the patient, who had insisted on sipping water, now howling. There was nothing I could do about her pain, but I figured I could keep her company, so I went back into her room and said, “May I take your hand?” and I sat for 15 or 20 minutes holding her hand, until she thanked me and murmured that she was going to try to sleep.

A couple of days before, rounding in the cardiac ICU, I introduced myself to a large, muscular fellow who, when I asked him how his spirits were (a new question I was testing that day), yelled angrily, “My spirits are great! I’m a believer!” I could see his wife across the small room smiling indulgently at him. I didn’t prolong the visit and decided not to visit this patient again, since he hadn’t seemed to enjoy our first encounter, but two days later, when I was passing his room, he yelled, “Chaplain! Hey! Can you come in and pray for me?”

During the prayer, I peeked at him and saw he was in tears. After the prayer, he spoke for 20 minutes or so about his fears and regrets. The next day, as I was getting ready to print out a list of patients to see, I heard the patient screaming and swearing and saw that he was having a conversation with four or five physicians. He was clearly in emotional distress, which is my department, so I hastily logged off the computer and politely made my way past the doctors to stand next to the patient, who was cursing and bellowing that he was going to do this and was not going to do that, and he didn’t give a f*ck what anyone else thought. Glaring at the doctors, he finished by saying he was going to leave the hospital against medical advice. The physician leading the discussion finally said, “Fine,” and left the room with the other doctors.

I spent the next 90 minutes with the patient, listening while he talked about his worries, various traumas he has suffered, and what will happen if this happens and what will happen if that happens. Now and then, I inserted a reality check: “Are you sure that’s true?” I also asked if there was any way he could upgrade his main demand to a strong preference. After a while, I asked, “What does the soberest and wisest part of you think you should do?” He said, “That part of me thinks I should stay in the hospital.” I observed, in a low-key manner and not at length, that when we consider how this and then that might happen, or that and then this, a lot of energy is draining away, since we don’t have any idea what will actually happen. “Maybe it’s best to take it one day at a time,” the patient agreed.

By the end of the visit, he said he was not going to leave AMA, and that he was going to stay in the hospital for at least the rest of the day, and he seemed to be at peace with the idea of being in the hospital for the next week. I applauded his ability to pause and consider the best course of action, his ability to be honest with himself and others, and his integrity, all of which had come through clearly.

Hoping to impress the palliative care team, I wrote a long, long chart note that mentioned all my wonderful interventions, which were far more numerous than usual. On our second visit, the patient had mentioned various treatment options. During the third visit, he often seemed sunk in pessimism, which to me did not seem warranted.

The next time I worked, I looked at the patient’s chart and was dismayed when I saw that his view of his prognosis was the simple truth. Where the talk about various options came from, I don’t know. Now hoping that no one had seen my idiotic chart note, I hastened to edit it. What I had thought were efforts to orient the patient to reality were actually efforts to instill hope where there was little basis for it.

I visited the patient that day. He spoke about being at peace with his own death: “If it’s my time, it’s my time.” He was happy when I arrived: “I told people you were going to come and see me today.” And he easily said goodbye when the visit ended, as casually as if we’d see each other again the next day, when in fact it was our last visit, or would have been if I were a little bit more adept at dealing with my own countertransference.

At the end of the day I went to see him for truly the last time, in the new unit he’d been moved to prior to discharge. He didn’t need to see me. I needed to see him. What did I want from him? Not anything in particular. I think it was my own stuff about death that made it hard for me to let go. I had become attached to this person, and I just didn’t want him to die.

His new room had an incredible 90-degree view, and as we sat together for a final hour, the sun began to set. It was an incredible sunset. It was as if nature was trying to tell me—I don’t think he needed to hear it—“Everything dies. Everything dies. But it is stunningly beautiful while it’s here.” At every stage of vanishing, the sunset was lovely in a new way.
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