“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.
