Friday, August 16, 2013


“Thank you, doctor, for giving us closure.”

That was what the patient’s sister said, in between shedding tears, as she gathered with the rest of her family inside the humid, overcrowded emergency room of the country’s biggest tertiary hospital. A frantic call in the middle of the night relaying news of her brother’s moribund state had forced her on the first flight back to the Philippines, and her weary face was at once a tapestry of mixed emotions: denial, grief, desperation, guilt, and finally, acceptance. Earlier that morning, I had engaged the family in an exhaustive talk that entailed a detailed explanation of the patient’s condition (best summarized as terminal cancer, comatose, poor prognosis), available options (to resuscitate or not, to continue aggressive medical management or not), and continuous reassurance (whatever your decision is, we will still provide the best possible care.) In the end, everyone settled for a quiet, non-intrusive approach that allowed the patient a peaceful death; no hefty measures.

Medicine in the new millennium has always focused on the quest for innovation: new drugs, new tests, new surgeries. These advancements in health care enabled doctors to work at a faster pace and deliver better outcomes, but somehow at the expense of less patient interaction. In an age where speed is king and efficiency is the rule, barely enough time is spent explaining the nature of the disease, offering diagnostic and therapeutic choices, providing ample reassurance – things which are incidentally just as important as their biomedical counterparts.

I, too, used to believe that the magic formula of “subjective-objective-assessment-plan” – so lovingly imparted to us in medical school – was the celebrated panacea to all my patients’ complaints. There’s the stirring fire of youth and idealism, plus the messianic way Filipinos often regard their doctors (As one patient entreated with supplication, “Kayo na po ang bahala sa lahat.”) During my residency training in Internal Medicine, I was stationed inside a government institution bursting at the seams with patients from all corners of the country. A lot of these were intriguing, complicated cases, and I was determined to push for gallant interventions no matter what. Many times, however, after an overwhelming rollercoaster ride that cost my patients an arm and a leg, I ended up tired and frustrated – a good number died despite my best efforts, and I further faced relatives who were just as confused, angry, and depleted to the hilt of financial and material resources. What happens when even the most exacting principles of science cannot give us solutions? What happens when even our noblest intentions fail to prolong life?

And then, my patients slowly taught me the value of the talk.

By talking, I mean a frank, honest, no-frills talk: A talk that raises no undue expectations; only real ones. A talk that might sting with the intensity of freezing water, but which will lead to a much-needed, much-yearned closure.

The realm of medicine is a rapidly evolving one, with mysteries lurking at every corner, answers waiting to be unearthed in the depths. Dr. William Osler, the pioneer of modern medical teaching, often preached that the role of a doctor is “to cure sometimes, to relieve often, and to comfort always.” Cure is perhaps the most tangible concept, manifest in the myriad breakthroughs and discoveries of medical research. Relief, too, comes in the form of alleviating pain and affording a more acceptable health-related quality of life. But comfort is rooted deep in empathy, the embodiment of an innate desire to help a genuinely suffering person. Despite the inherent shortcomings of our relatively resource-poor health care system, I realized that proper and meaningful communication seemed to raise the bar each time I sat down with a patient and/or his/her relatives, making the experience much more personal and profound. I eventually learned to throw away the proverbial coat of invincibility and omniscience and lay down all my cards: As physicians, we may not always have the remedy to every ailment – but we are there to reach out a hand, to walk every step of the way.

It is a task both daunting and difficult, especially when you find yourself confronted with a visibly distraught husband, a daughter transformed into a huge bawling mess, or several passionately argumentative family members. And perhaps quite understandably so. For how could a star athlete suddenly succumb to a heart attack? (“Hindi ito posible,” his bereaved girlfriend pronounced.) How could someone walking and laughing a few minutes ago abruptly collapse from a massive stroke? (“Paano nagkaganyan?” The horrified brother countered.) Discussing advanced directives, in particular, is a delicate matter. Many family members are unwilling to make decisions for an incapacitated patient even though they possess the legal right to do so. “Ayoko masisi ng mga kapatid ko,” reasoned the eldest son. “Hintayin na lang natin ang aking manugang,” begged the elderly wife. It takes a lot of patience and perceptive acumen to guide the surviving family members through the crucial process, but it is a necessary means for closure – and the result can prove both enlightening and empowering.

More than anything, helping people achieve closure made me marvel at the unique strength of character, the tightknit closeness of kith and kin, and the earthshaking, resounding faith in God that proudly characterizes the Filipino spirit. I met families who chose to have their loved ones spared from traumatic intubations or fractured ribs from excessive chest compressions during resuscitation. I met families who chose to forego gargantuan procedures bordering on the futile, with a firm decision not to pursue the farfetched moon and stars. I met families who nodded with understanding, who managed to smile despite the grim reality, who offered gestures of gratitude for words well-spoken and time well-spent. I met families who saw the value of dying peacefully.

Looking back at that pivotal moment in the emergency room, I may have failed to keep the patient physically alive, incurable as his disease is. But it warms the heart a little to know that I was able to share what little time I had with the family he left behind – now coming full circle, now cloaked in mourning, now bonded in closure. I am reminded of Dr. Osler’s fabled words to “cure sometimes, relieve often, comfort always,” and just like that, I learned to find it in myself as well – a certain kind of closure no amount of medical training can ever give.

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