health

Moments Matter 70: Two Weeks

It’s been a tough day.

I’ve stared at those words for a while now, unable to write anything after. And while I stared, a day became days, and then a week. And now, it’s been a tough two weeks.

I pride myself in being able to sit with differing opinions, to hold two things in one hand and consider them from all angles, to weigh them both, to see the qualities inherent in both, to imagine a situation in which I might choose the one over the other. It is, after all, what I do most often as a palliative care doctor. It’s how I’ve built my life, and how I’ve raised my kids. But lately, I’ve struggled to see things from both sides.

It’s been a tough two weeks. It’s been tough watching core values, values that guide every passing second of my life, values that shape who I am as husband father doctor human, so brazenly challenged and mocked and torn down.

It’s been a tough two weeks. It’s been tough watching something I’ve dedicated my entire life to – the study of science, the belief that we as people are better for asking hard questions and relentlessly pursuing the truth even if we’re proven wrong – so brazenly challenged with little regard for consequence. It’s been tough watching something I’ve dedicated my entire life to – the empathetic and compassionate treatment of all people – so brazenly challenged. Tough watching violence condoned and bullying lauded.

And now ICE and CBP agents can enter our churches without seeking further authority. And now, too, our hospitals.

I’m all for re-evaluation of policy and restructuring and change, and I’ll be the first to agree that change is needed in our country on many levels and on both sides of the aisle. But not at such a cost, never at such a cost. Never at the cost of sacrificing values that should, and must, be universal. Respect and tolerance and equality and compassion and empathy. Life is not fiction, it is fact. Freedom is not fickle, it is doing and saying and protecting that which makes us all feel free, be free.

All of us. Together.

I’ve struggled internally with whether to post this or not: it has lived as a draft, in one form or another, for two weeks. These thoughts are my own, though I’m comforted knowing that a great many share them. At the end of the day, I reminded myself that I write for my own health, that I write because I must, that it is my way of healing and moving on. And I reminded myself that this is not a political blog, it is a health and wellness blog.

And I reminded myself that this is not a political post, it is a health and wellness post. For me, for my children, for our country, for the world.

Moments Matter 62: It’s Not Just a Matter of Time

I feel like we spend a lot of energy thinking about prognosis in terms of time, but it’s not always a matter of time. In fact, for many of my patients, “how much time do I have left” is often less important than “can I feel, in some way, like myself again?”

This is a pretty well-understood concept in palliative medicine, the concept of quality of time vs quantity of time. And yet, when we discuss prognosis with our patients, we tend to speak in hours to days to months or years – we tend to assume that the most important, or relevant, aspect of prognosis is time.

Reframing prognosis in terms of what matters most is often helpful. Temporal Prognosis may take a back seat to Functional Prognosis, or Identity Prognosis, or Legacy Prognosis. This is something we consider quite a bit in our inpatient rehab and stroke units where physical function and independence are typically affected. A REMAP headline may become less about “time is short” and more about what it is, or is not, possible looking ahead.

And if you’re unsure about which type of prognosis matters most to your patient? Then the best thing to do is explore with empathy and curiosity (an “I wonder” statement may work well here!).

Moments Matter 60: Introduce Yourself, Part 2

We talked previously about the importance of introducing yourself when entering a patient room, but one question I get asked a lot, especially at the beginning of the year, is: “how exactly do you introduce palliative care? What are the specific words you use?”

So, with newly matched HPM fellows eagerly anticipating their first day on service, I thought I would share the exact words I use, and open things up for advice from colleagues in the field.

First, a polarizing topic: should you introduce yourself by your first name, or by Dr. ____? This question usually elicits a mixture of eye-rolling and heavy sighs and maybe some anxiety, but it always comes up. Always. My take is this: introduce yourself the way you want to be identified. I’ve seen it done many ways, and I’ve heard compelling arguments all around. It’s a more complex and nuanced issue than I have space to explore here, so that’s all I’ll say about it for now.

Next, I usually say “I’m with the Palliative and Supportive Care team” (your institution may have a different title for your service). Seems like an obvious next step, but as I’m speaking these words, I’m looking for non-verbal cues, signs of recognition, indicators of prior experience with palliative care either positive or negative. The sigh of relief. Shifting in the seat. A break in eye contact. I might pause for a few seconds, and then explore the non-verbal reaction (ie “It seems like you’ve heard of palliative care before?”) or just go ahead and ask “Are you familiar with palliative care? What have you heard?”

If there’s misconception from the start, like Palliative Care = Hospice or Palliative Care = Death, then I correct the misconception with empathy. The sometimes unanticipated challenge of introducing palliative care, compared to other specialties, is that hearing “Palliative Care” may be perceived as “Bad News” and you may suddenly find yourself in the middle of a difficult conversation before you’ve even started. I welcome this as an opportunity to explain what I do with compassion.

The words that I use are typically some variation of: “I’m here to make sure we’re listening to you and getting to know you better as a person. This will help us come up with a medical plan that best matches your hopes and values.” I might change it up a little depending on the situation, but that’s pretty much what I’ve settled into over the years.

And the truth is, I’ve never had anyone say “that sounds like a terrible idea” after framing it that way. But I know for a fact that there are many, many ways of introducing our specialty.

So the big question: how do you introduce palliative care?