Saturday, October 09, 2004

Don't Be Afraid to Say "Cancer"

Recently, most of my palliative care patients have been comatose. My work was focused on keeping them comfortable and guiding the families to do the "work" for their dying loved one.

"Tell him what you think he did well in his lifetime. Tell him you forgive him and ask for his forgiveness." I would explain that this is the end-of-life work that their loved one would be doing out loud if they were able to. "Help her make peace with her life."

Yesterday, I had two palliative care patients, both of whom were fully awake. It had been weeks, possibly months, since I'd had a patient who was alert and it kind of threw me off. I'd become so comfortable with the families, but suddenly felt estranged from the patients themselves.

The main thing I try to focus on when with the people who are dying and their families is to be open to using the words that so many avoid out of discomfort. Don't be afraid to say: death, dying, cancer, end-of-life. Acknowledging the pink elephant in the middle of the room frequently is a large part of this work. However, I'm still not quite suave with these conversations.

One of my patients yesterday was confused. She didn't even know her own name, let alone recall mine.

"Do you know who I am?"

She shook her head no.

"I'm Mia. I'm your nurse," I explained. "Do you know where you are?"

She again shook her head no.

"You're in the hospital."

She looked at me blankly.

"Do you know why you're here?"

She again shook her head no.

"You have cancer."

She continued to look at me blankly.

I felt frustrated. I wasn't sure she understood what I was saying. I had to leave the room for a moment and then came back.

"Do you remember who I am?" I asked again, to assess her short-term memory.

She again shook her head no.

"I'm Mia. I'm your nurse," I reminded her.

I had met with the palliative care team that afternoon and they'd explained to me that their goal was to keep her alive for another two weeks until her daughter's wedding.

"So, I hear there is going to be a wedding." I looked to her husband who had just arrived and then looked towards the patient. The patient looked at me with excited surprise in her face. She didn't seem to have heard the news. I again assumed she must be confused.

Her son then entered the room and approached her bed to kiss her hello.

"I'm sick," she informed him as if she had just learned this fact, though she'd been in the hospital for weeks. Suddenly, I wasn't sure how confused she was. Did she just figure that out from me? Surely the doctors had told her of her prognosis, as they had signed for her to be made palliative care and had signed the DNR/DNI orders. Did the emotional impact of my pronouncement ingrain it more solidly into her fragile memory?

I had worked hard to overcome my timidity in approaching these subjects with her. But in retrospect, I wish I had started the conversation out differently.

"Tell me what you understand about why you're here." I have been taught over-and-over: use open ended questions. The awkwardness I still feel during these conversations wipes out the basic communications lessons I've learned over and over.

Someday I hope I get it right. In the meantime, I hope my stumbling at least had the side effect of opening a door for the family to start talking directly about the fact that she is dying.

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