Tuesday, October 12, 2010

More on Mortality

This past weekend I attended a course--Practical Aspects of Palliative Care--held by palliative care physicians and specialists from Harvard's hospitals.  It was attended by physicians, nurse practitioners, nurses, managers, social workers, and chaplains from across the country.  I was very different.  Greener than green, I have not yet taken part in the dying process, much less the process on a regular basis.

Apart from seeing glimpses of cadavers in various anatomy labs while interviewing at medical schools, I have only seen a dead body once in my life.  It was in the basement of a hospice I had volunteered at in college, and what struck me was how lonely it looked.  Fewer than 24 hours ago, that same figure had been surrounded by doting loved ones whispering tearful expressions of affection.  She had been the center of attention, of love, of comfort care.  She had appeared almost identical to how she looked now, but everything else had changed.  She was alone on a cold metal gurney.  When the volunteer coordinator turned off the light and closed the door to the basement, I had an instinctual reaction--wait, are we just going to leave her there?

Later, outside the confines of the hospice, I probed my discomfort over leaving, and I realized how difficult it was for me to separate a body from the person who had occupied it.  For better or for worse--despite rational mind-body dualism--we are our bodies.  When our bodies fail, who we are is profoundly affected.  When we're in pain, our relationships with others change.  When we don't have energy to speak or to move, some priorities shift to the forefront while others fade into the background.  Health is a foundational good that we can take for granted until its status changes.

During the conference, there was a workshop on how to avoid burnout and fatigue.  Participants listed the "perfect storm" of events that could cause them to hit an emotional wall.  For some, patient-related issues contributed: seeing particularly young people die, or seeing people who bore striking resemblances to themselves.  Professional dissatisfaction was a cause too: feeling a lack of control over the system or over resources within the system, or not being able to help as much as one would like.  Personal life certainly played a role, as well as general challenges unique to working in palliative care.  Who do you turn to when you need to share something particularly challenging or frustrating?  Do those outside the field understand--and even if they do, how often can they hear about it?

I waited to hear answers along a particular line of thought.  Loss of faith.  Spiritual questioning.  Seeing so much suffering as to feel as though life itself were unfair and meaningless at times.  Existential anguish.  These were noticeably absent; answers were fairly grounded.  I'm not sure what that means.

I wonder if it takes a particular type of person to go into this field.  Does the special emotional resilience--the ability to transition from distancing to empathizing--stem from deeper beliefs about life?  Do you have to have some sort of spirituality or religion to give events a greater meaning, so as not to become disillusioned by the physical fragility of the human condition?  I would very much like to know if palliative care professionals are more spiritual/religious than other health care professionals, and if so, if it's correlative or causative.  At a certain point during the course, I began to see all of us as the walking future dead.  How could these professionals see such tragedy and still function despite these continual reminders of their own fate?  I think this is something I am wholly unprepared for and will have to learn gradually.

Death isn't carved out neatly into palliative professionals' hands simply because they have more experience with it.  Most doctors will have to face it.  I will be facing it during my third year of medical school.  I will be facing it in two days, in seeing my first "patient," a cadaver.

It seems like a great juxtaposition to go from a palliative care conference--focusing on transitioning from the living to the dying--to the anatomy lab--focusing on learning from the dead.  It seems like an odd backwards cycle, but I'm glad for it, emotionally.  There will be no suffering, no unmitigating symptoms, no difficult decisions.  Our learning takes place after all this, from the great gift left behind.


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