Palliative Care. A Student's Reflection

Over the summer, BUCK funded a $1,000 stipend for a medical student to participate in a rotational program in the integrative medicine unit at MD Anderson. The student was Margaret (“Maggie”) O’Brien, who is enrolled in the Medical Humanities Scholarly program at the University of Texas. This program is focused on bringing the patient doctor relationship back to medicine. Maggie beautifully summarized her experience during her rotation.

By Margaret (“Maggie”) O’Brien.

“No place better bookends the opening and closing chapters of life than a hospital. It’s what first drew me to medicine, volunteering as a cuddler in the NICU. During my high school years, I spent Saturday mornings holding babies connected to tubes and machines, watching them grow and go out into the world. It seemed only natural that my first summer of medical training should be spent learning about the other half. Having lost most of my grandparents to cancer at a young age, my understanding of the end of life was minimal: an afternoon watching hospice nurses cover the dying elderly with handmade crochet blankets. An hour in the ER where I silently watched from the corner as a veteran’s heart slowly failed. My tank in anatomy lab, where my team and I honored our cadaver through dissection and diligent study.

I’ve always known that as a physician, it would be my duty to be with patients in their most difficult times. It is hard to imagine a setting more difficult than suffering from terminal cancer. I chose to rotate with palliative care in an attempt to become competent around and find comfortability with the pain of such suffering. What I didn’t expect was for palliative care to encompass the full spectrum of supportive care of MD Anderson patients. I had no idea I would be immersed in a truly interdisciplinary team, devoted to not only the care of their patients but also to the patients’ families and even for each other. As one supportive care physician explained to his patients, the oncologists are here to treat the cancer, palliative care is to take care of the patient. As I reflect upon what I learned during my rotation, it is the philosophy of patient-centered medicine that I saw practiced every day that sticks with me most.

My time at MD Anderson began in the Palliative Care Unit, the inpatient unit which houses patients in need of complicated symptom management. The palliative care attendings and fellows rounded gradually with only paper, pen, and stethoscope, never letting the accoutrements of modern day practice interfere with the greater role of connecting with the patient and patient’s family. They listened with patience and generosity, waiting in the pauses of silence in conversations to allow family members the space to speak up. They watched the patients breathe and gurgle and moan with concern and compassion. As the days slid by in a haze of lavender aromatherapy, the physicians answered the same questions with clarity and repetition. There is an understanding that this a world that most know nothing about and few enter gladly. Each family is reassured that if needed, the doctors will be right outside the door, alongside the nurses, counselors, social workers, case manager, and chaplain. Nowhere are the social dynamics of a family and the psychosocial elements of patientcare more critical than in palliative medicine, making the successful cooperativity of an interdisciplinary team a necessity. They say it takes a village to raise a child, but the same is true at the end of life.

I find a new context for the opioid epidemic in its use for cancer patients in the Supportive Care Clinic. Patients who need opioids the most are often reluctant to take them for fear of becoming addicted. Dr. Hui uses a metaphor to educate his patients: think of opioids like a knife. Used in the wrong context, a knife is a dangerous weapon. Yet, it would be extremely difficult to cook without a knife to cut and chop.

Most cancer patients approach taking pain medications with apprehension, but there were also those whose behavior and history trigger flags for chemical coping.  One patient showed up intoxicated, refused a urine test, and demanded a month’s worth of oxycontin. She stormed out when her request was denied. Another patient was a man who spent his life battling drug addiction, hesitant to take the pills he felt defined so much of his life, only to find them a necessary blessing at the end. There is a sharp point to Dr. Hui’s metaphorical knife, one I felt acutely the day a patient told us that his teenage daughter overdosed on his prescribed morphine just days earlier. The encounter is one so fraught and distressed that the very air in the clinic seemed to tingle with tension. Over and over again, the patient moaned that no parent should have to bury their child. His words clotted in my ears like wax.

It is this very reason that pediatric palliative care is a whole different animal, as I discovered during my time on the consult service. During my few days in the children’s wing, we suited up in gowns and gloves and masks to meet with a teenage boy who never looked up from his videogame. I could not imagine why he wouldn’t talk about his pain, his symptoms, so that they could be fixed. The attending explained that his video games were his escape, and we were the ultimate intrusion to the fantasy. The next day, I noticed that the video game avatar was a character so encased in armor that even his face was covered and his arms were connected to the swords he carried. A far cry from the shirtless boy on the bed, connected to a web of IVs through his arms and stomach.

There are also patients and families that recognize the extraordinary in their treatment team, as I did. They would wonder aloud how anyone could possibly come to work every day, knowing what challenges and pain they would face. I wondered this too at the start of my rotation, but I have my answer now. As a doctor, there is almost nothing more rewarding than taking someone’s pain and problems and helping them feel better. It is why most people go to medical school in the first place, to desire to relieve suffering. This simple idea is the heart and soul of palliative medicine, the reason it is needed as a field so profoundly, and the motivation to choose it as a career.

Although I still cannot say definitively what my future plans will be, I know I will strive to incorporate these ideals in my future practice. My six weeks rotating in palliative care taught me so much about the juxtaposition of life and love among suffering and death. My time there as a rotating medical student was more eye opening than I could have imagined. Every day when I walked in, I felt reminded me what was really important. Pain may be the great equalizer, but there are things it cannot take away. The love of families who gather around their own and fill the room with their love. The faith in God that lifts the spirits of those whose bodies have been dragged down. The memories that one has the chance to make up until the final breath. I am reminded that each day good or bad is a blessing, that the time I am given is an immeasurable opportunity, that the life I am living is my only true possession, that my faith is a renewable source of strength, and that love is the greatest joy. The gift of perspective is a powerful strength, one I hope I will take with me on the journey of my medical career and the rest of my life.”

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