Medicine from the heart . . . Jennifer DePiero, MD

On Thursdays, the Daily Voice showcases selected Thursday Morning Memos, reflective essays about clinical experiences written by faculty, alumni, residents and students of the Department of Family Medicine & Community Health and, occasionally, contributors from other departments. Thursday Morning Memos is UMass Medical School’s homegrown version of narrative medicine, in which the authors process their experiences through writing. To learn more, visit: http://www.umassmed.edu/news/articles/2011/personal_stories.aspx.

A graduate of the School of Medicine’s Class of 2011, Jennifer DePiero, MD, writes from Maine Medical Center, where she is an intern in family medicine. Her story is from her last elective at UMass Medical School with the palliative care team, where she learned the importance and grace of simply listening. –Hugh Silk, MD

Grateful for Listening

When we first heard about RT, the local palliative doctor and I were told that we would fall in love. We were sitting in the comfortable office of the cancer care social worker. Apparently RT made an impression wherever she went. She was young, had just passed a major professional development exam six months ago and still worked despite increasing pain. She had a loving husband who came with her to every appointment.

But it was also the disease itself that gave people the inkling to love RT—the tragedy of a progressive breast cancer. A cancer that grows like yeast in a measuring cup in the warm corner of the stove. Breast removed, in six months RT had tumors creeping up and down the left side of her chest, most recently starting to show angry and red at the surface of the skin where her breast had been still soft and full only a year ago. The cancer was in her bones and her arms. She was getting radiation in two spots and had lymphadenopathy that throbbed unless the arm was wrapped tightly in an ACE wrap.

When we met RT, she had been sitting for 24 hours with the bad news—that treatment could continue to try to slow things down, but there was no chance for cure. She had been to three appointments the day before, including an MRI at 11 p.m., and today was in the midst of four appointments, almost ensuring that her entire day would be spent in the hospital. We listened to the story of her pain and of the care that was holding her together. We advised her about pain management and how to get services at home. We talked about hospice with all the non-threatening caveats we have learned. This was made easier because RT and Mr. RT were generous and honest people, and their love for each other spilled across the small round table in the consult room, enough to hold us all aloft for hours.

They shared with us how RT kept a blog to keep friends and family informed, but that she would never write until she had some good news to temper the bad . . . “They found a spot on my vertebrae but I will start radiation for this tomorrow.” How would she temper this final news now that she knew this disease was going to end her life? This is the transition of the work we all do in palliative care: a switch in the focus from getting better to being well in the context of dying. Perhaps the same tools that patients and families use in that epic “fight” can serve that transition. And the challenge of letting go can then bring in gifts of spirit, a different kind of hope that we don’t know we have.

Speaking for them both through the tears filling his eyes to brimming, Mr. RT said that they have a deep comfort despite the struggle of this disease and the impending loss because “we like who we are and where we are.” And here, on those words, we could all rest for a minute in this clarity. Each day we bring with us exactly what we choose to be. We make it our business in palliative care to bring to the dying "dignity." We know also that dignity may be different for each patient. Sometimes there are patients who redefine this dignity, and by listening and watching, we gain skills to take with us to the others who will come for guidance and assistance.

I am grateful to all my teachers throughout life who have taught me to listen. I am grateful to have listened and to be able to witness the simple wisdom that some can share through a lens of love and contentment. And I am grateful to RT and Mr. RT for sharing their story and bringing their presence alive to us that day. I do hope our patients know when they thank us at the end of a consult—for bearing witness, for sharing their pain, for giving advice or explaining something difficult—that we are as grateful to them for the privilege to hear and hold their stories. RT has a difficult journey ahead. She and her partner will need a palliative team to help care for her symptoms and guide them through changes—physical, psychological and spiritual. But they in many ways they already know how to do this dying, and we need to listen.