Abstract
I
Jim's admission to my hospital team was for “constipation” that was causing intractable nausea and vomiting. The oncologist advised us that he was an angry patient who had not accepted the fact that his inoperable, widely metastatic pancreatic cancer was going to end his life in the weeks to months ahead. The oncologist shared that Jim didn't want hospice, that he was determined to fight on. He was a career soldier and officer, and soldiers don't quit. His mission was to fight this cancer.
In reviewing his history, radiology results, and labs, it seemed to me that the only thing inside Jim's intestines were metastases from his cancer. To me, his “weeks to months” prognosis was overly optimistic. As long as he didn't eat, he wouldn't vomit. But he wanted to eat, ice cream especially, and everyone wanted him to have that simple pleasure.
Jim's wife, Janet, said that his chemotherapy had been a nightmare—nothing but doctor visits, treatments, vomiting, pain, anger, and frustration. She wished they had spent that time on a beach away from hospitals. Beaches, traveling, and family—that was the plan for their retirement, until his symptoms developed.
My sense of urgency was building in the days that followed as the intensity of his distress and anger rose. He did not like what he was hearing with regard to a lack of curative care. I felt it was time to have a real discussion with Jim and his wife about the goals of his care, and that we could successfully palliate his symptoms. While I do not routinely use “Military Speak” in my day-to-day clinical encounters, this day was different. “Military Speak,” or MILSPEAK as it is known in the business, is the succinct communication between soldiers about the situation, resources, and planned course of action. It provided us a common language to use to discuss the future.
“The status quo isn't working,” I said. “There's no cavalry coming to get rid of this cancer, and the only realistic exit strategy is to control your symptoms and keep you comfortable until your death. You probably have only days to weeks to live. Hospice is the cavalry to help you and your family.”
Jim's response was as pointed as a bayonet: “What will hospice do that you're not already doing?”
“There are lots of different types of therapy that will help you and your family—day-to-day assistance, spiritual help, social work, massage, music therapy…”
“Music therapy?”
“Sure,” I responded. I sensed an opportunity, and I smiled. “What songs are your favorites?”
Jim paused, and a slight smile spread across his lips. “I hate his politics, but I love Elvis Costello's music.” He looked lovingly at his wife. “Honey, do you remember his concert we went to in college?”
Janet gleamed with a knowing smile, and her eyes lit up as she recalled pleasant memories. This was the first moment of peace I had seen in her throughout the hospitalization. “Sure I do…”
I sat in awe and admiration as they sang and hummed ‘their song’ together:
“As I walk through this wicked world
Searchin’ for light in the darkness of insanity.
I ask myself, is all hope lost?
Is there only pain and hatred and misery?
And each time I feel like this inside,
There's one thing that I wanna know:
What's so funny ‘bout peace love and understanding? Ohhh
What's so funny ‘bout peace love and understanding?”
—Elvis Costello, “Peace, Love, and Understanding”
It wasn't long thereafter that Jim agreed to enter hospice, and we began making arrangements to get him home with his family. Prior to his discharge, a priest visited and administered the sacrament of anointing of the sick. As I watched Jim's eyes close and his hands come together in prayer, I was filled with the uneasy vision of him lying in a coffin. I held a sick feeling that time was running out, and that he had only days—not weeks—to live.
The family all arrived, and they circled their wagons. He died three days later, eating ice cream and listening to Elvis Costello and the Beach Boys. The nurses and aides tended to him; family and friends came by to say goodbye. It wasn't the beach, but they were home. I had never thought of hospice as the cavalry before, but they were—they saved those last days for him and his family. I think that as a soldier, Jim knew that in war, the end of fighting is usually a good thing. Peace can follow.
I have always needed closure after the death of a patient, especially a kindred spirit. As I arrived at Jim's memorial service, I was welcomed by the music of Elvis Costello playing in the background. His friends and relatives congregated around photo albums, laughed at a compilation of family videos, and marveled at his military decorations and awards. To my surprise, there was no trace of the angry patient I had met. Jim had been a healthy soldier, surfer, karaoke singer, and family man—a leader, friend, and fighter.
I left Jim's memorial, silently thanking a musician I have never met for a song that helped my patient accept an end to fighting, a transition to peace. I shared this music experience with a colleague who serves as a hospice medical director. He was going to start his upcoming lecture on hospice care with a song from the Moody Blues:
“When we go, we never return
‘Cause there's just one lesson
That we got to learn
Wherever you go, whatever you do
Whatever you say, say, say, say
Say it with love”
—Moody Blues, “Say it with Love”
A great song with a great message—it's the second song on my Hospice Playlist.
Aging Songs Playlist
“Too Young (to feel this damn old)” by Garth Brooks
“Glory Days” by Bruce Springsteen
“We Didn't Start the Fire” by Billy Joel
“As Good As I Once Was” by Toby Keith
“School Boy Heart” and “Growing Older But Not Up” by Jimmy Buffet
“Singing the Dinosaur Blues” by Jerry Jeff Walker
“Still a Little Chicken Left on That Bone” by Craig Morgan
Hospice Playlist
“Peace, Love, and Understanding” by Elvis Costello
“Say it With Love” by the Moody Blues
“Gone, Gone, Gone” by Phillip Phillips
“Live Like You Were Dying” by Tim McGraw
“Handle With Care” by The Traveling Wilburys
“When I Get Where I Am Going” by Brad Paisley
“You Lift Me Up” as sung by Josh Groban