Abstract
When I heard that there was a mandatory 4-week rotation in palliative medicine in my family medicine residency, I almost changed specialties. That's how scared I was of palliative medicine. How could I possibly help someone in the final stage of their life? How would I know what to say? How would I come to grips with my own fear of dying? I was worried that I wasn't a good communicator, and didn't show empathy. These questions and thoughts would keep me awake into the wee hours of the morning in the months leading up to my rotation. Compounding my anxiety of palliative medicine was stress and fatigue as my first year of residency was emotionally taxing. What more did I have left to give?
On the first day of my palliative medicine rotation, I was nervous before the day even started. Then I met my preceptor. She introduced me to her patients, taught me pearls of patient care, and hugged me at the end of the day. I was surprised to find that the next morning my nerves had eased. By the third morning, I was excited for work and brought home a palliative medicine textbook to read that evening—something I hadn't done for a long time while I was struggling with burnout.
The following week I was asked to have a code status discussion with RJ. She was a 55-year-old retired housekeeper who had been transferred to the palliative care unit for the weekend. Unfortunately, she found out only eight days before admission that she had metastatic pancreatic cancer and she was deteriorating rapidly. JR had significant abdominal pain likely from ascites and a high tumor burden, nausea, vomiting, electrolyte derangements, weakness, fatigue, and dyspnea. Despite this, her code status was “C2” on the electronic health record (which means “full code” in British Columbia, including CPR, intubation, and ICU transfer).
I felt daunted by the idea of having this discussion with JR and her family. As a new doctor, I was still learning how to have conversations about end-of-life care and code status; at times it felt clunky and awkward, and I worried about how this would impact my patients. Nonetheless, I reviewed JR's chart, wrote down some notes and conversation prompts and, with my heart thumping in my chest, knocked on JR's door to introduce myself.
JR was a strong, stoic, and feisty woman. She immediately requested that we move our discussion outside into the sunny courtyard so that she could have a smoke. JR, her mother, her daughter and I all gathered around a table—partially exposed in the sun, partially shaded—to begin a difficult conversation. Initially, JR remained distant and downplayed how she felt about having pancreatic cancer, shrugging it off. But slowly, as I offered moments of silence in our conversation and she neared the end of her cigarette, she began to open up about the shock and fear around receiving her diagnosis, her pain and suffering, and lastly about her grief of missing the upcoming birth of her grandchild. JR shared with me that her daughter, who was present at the meeting, was 16 weeks pregnant. On the one hand, JR voiced a strong desire to move toward comfort care; on the other hand, she was holding on to the chance to meet her grandchild. Although my knowledge and comfort of palliative medicine was still in its infancy, women's health and obstetrics was in my comfort zone and is my passion. After some thought, I said to JR, “how would it be if I could show you your grandchild on ultrasound right now?” to which she nodded a “yes.”
It was settled. As JR's daughter went to pick up an apple pie (JR also told us she wanted to eat apple pie one more time before she died), I scoured the hospital for a portable bedside ultrasound. We reconvened in JR's private hospital room one hour later to meet JR's grandchild. While we watched JR's grandchild wiggle and squirm on ultrasound and JR ate her apple pie, I looked around the room and saw tears. In that moment, I felt my own heart swell with emotion.
This was the first time as a doctor that I felt as though I had made a significant difference in a patient and family's life.
After I performed the bedside ultrasound, JR fell asleep. The next morning when I stopped for rounds, JR's daughter told me “mom didn't ask to smoke this morning… something is changing.” In the wee hours of the following morning JR died.
My involvement with JR's end-of-life care was a privilege. I am thankful that I had the opportunity to meet JR and her family, and that I could incorporate my passion of obstetrics into her care. I have learnt that there are similarities in birth and death: both are varied and at times nebulous, can provide an opportunity to bring family together, and are unique experiences that can be wrought with emotions. Now, in my first year as a newly graduated family doctor I will strive to communicate with and support my patients in the same way as I did for JR and her family.