Making Sense of Medicine

To put it another way, the first day of grief increased the risk of MI by more than twenty times what would be expected on a day without such sorrow.

Over the years I’ve heard of multiple loving couples who have died within a week of each other. I’ve heard people say: “He (or she) died of a broken heart.” The above study, published in the medical journal Circulation, supports those comments.

What I take away from this research is a renewed resolve to do what I can to support people who are grieving. Grief is a painful time. The way “life was supposed to be” has been altered, perhaps abruptly. I was walking purposefully down one path, thinking I could see my goal in the future, and now, suddenly, I am forced to walk down this other path, with no goal visible. The process of adjusting to this new reality is what we call grief. And it’s no fun.

Maybe all a grieving person needs is a wordless hug. I suspect that’s all that person needs. 

The study, published in the Journal of Clinical Oncology, followed terminally-ill cancer patients at the Dana-Farber Cancer Institute in Boston. First they assessed how much the patients leaned on their personal religious beliefs to cope with the stress of their illnesses. Those who scored highly in that assessment were the “positive religious coping” group.

There are decisions to be made at the end of life, such as whether to be intubated (a tube placed in the lungs) if breathing becomes too shallow to sustain life. As a doctor, it’s never easy to decide whether to intubate someone who is approaching the end of life, mostly because there’s usually no clear sign that death is inevitable. Getting intubated is one form of “aggressive” medical care. Basically, a doctor intubating a patient is applying advanced medical care with the implicit hope that the person will be able to be extubated (the tube taken out) and to be able to live some amount of meaningful life afterwards.

Sometimes the doctor knows the patient is dying and that intubation isn’t going to provide a meaningful extension of life. Yet if the family is insisting on it, I assure you the doctor will do it, unless the patient has made his or her wishes known in an “Advanced Directive”, asking not to have aggressive medical care given if it looks like death is looming.

So now – back to “positive religious coping” and facing death: The Dana-Farber study showed that “positive religious copers” who reported that their spiritual needs were being met by the hospital staff (both by the medical team and by pastoral care visits) were less likely to use aggressive end-of-life treatments, such as intubation. They were also more likely to use hospice, whose philosophy is to support and care for a person at the end of life, treating pain but not seeking to cure.

Also, everyone in the study who reported having their spiritual needs “largely or completely supported by the medical team”, whether they were “positive” religious copers or not, were found to have a higher quality of life as they approached death. 

The key for dying people is having their spiritual needs – whatever they are – satisfied. It sounds like Dana-Farber encourages their medical personnel to be sensitive to these needs, and that there are chaplains available. This combination is not present in every hospital (an understatement). The end of life – when we know it is coming – is generally a time of deep spiritual reflection. It only makes sense for hospitals, since they are places where people frequently die, to support people when they are asking the ultimate questions.

Responses to my last post, “The End of Life”, have reminded me of the importance of talking about the possibility of death when someone has a serious, potentially fatal, illness. Why do we shy from having this conversation?

I know why. It sounds like we are giving up, that we are no longer anticipating a cure. That is certainly the struggle that doctors have, when deciding whether to bring up the subject. I find that I can bring up awkward subjects more easily when patients are alone in the clinic room. When I’ve been people’s doctor for a while, I’ve had a chance to study their personalities, and can anticipate how they will respond to the information I want to share. I choose different words depending on how I want to approach an issue.

But when people are being treated for a serious illness, they are more likely to have family members or friends with them. I usually don’t know these people as well. How are they responding to this delicate conversation?

Don’t get me wrong – I love having family members and loved ones with patients in the clinic. Having extra people adds texture and depth to the doctor-patient relationship. I see people in a bigger context, getting a glimpse of the parts of their lives that doesn’t involve medicines and health.

The goal is twofold: One, to keep trying, keep working to beat back the disease, keep maintaining hope. And two, becoming prepared for the possibility that this will be the thing that leads to death. (There is a 100% death rate for humans, unless you are Enoch or Elijah from the Bible, who were taken straight to heaven.) Keeping these two goals in balance is tricky. Not impossible, but tough to achieve.