Yet requirements to practice medicine do not include even one day of clinical exposure covering how to recognize when death is approaching, let alone how to care for people as they are dying. Death is a blind spot in medical education.
Learning to say goodbye is part of the gap.
Before becoming a hospice physician, I became increasingly unsettled with how I left the patients I was caring for on the hematology ward in the hospital. It seemed three manners of departure prevailed: 1) if I were the person doing the leaving, I'd simply inform my patient my time on service was over and that Dr. so-and-so would be taking over for me the next day; 2) if the patient died, they would be treated as if they weren't dying until they did, and then essentially vanish without any further word; and 3) if my patient was discharged from the hospital, they typically entered what felt like a revolving door of planned (or highly anticipated) returns to the hospital for more chemotherapy or antibiotics for fevers that commonly develop in the setting of a weakened immune system. Whichever the case, none of these partings felt joyful.
That changed when I cared for Sasha.
Sasha had a very unusual leukemia that, like Marvin’s, had her undergo several rounds of induction chemotherapy. In her case, the third round made all the difference: her cancer was retreating, and she had become engaged to be married while enduring our care. When her bone marrow finally found a way to recover healthy cells to the point we could begin counting the days until she was going to be released from her isolation room and allowed to leave the hospital, I found myself becoming increasingly uneasy. I didn't know how I was going to be able to say goodbye.
I was seeing Sasha nearly every day through the intensity of each induction chemotherapy. I was watching her transform as the treatments intended to destroy the cancer cells simultaneously destroyed the healthy cells of her gastrointestinal tract from mouth to anus. Retreating like a caterpillar into a chrysalis, Sasha withdrew into silence. Both pain medicine and nutrition fed her veins as her mouth hurt too much to open. Days crept by waiting for the reappearance of healthy cells to begin healing her body. We knew the day she greeted us with a smile heralded the return of the healthy cells even before any blood tests could detect their resurgence. Seeing her smile stretch across her face was like watching the luminous wings of a newly hatched Monarch unfold. Our own masks prevented her from seeing the kaleidoscope of smiles that mirrored her own.
Protocols put in place to help keep our patients protected from infection included having our team and all visitors gown, glove and cover our faces with masks and our hair with bouffants. The only distinguishing feature patients could use to tell us apart (apart from our height and voices) were our shoes! It became an unspoken challenge amongst our team members to wear the most distinctive shoes possible to bring a bit of levity to our patients and, I suspect, to ourselves.
Sasha was the first to comment on my green suede boots with pink and brown flower embellishments at the ankles.
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