Living Will

This is my wish,
when my voice becomes too soft to hear.
If you cannot do these things,
I understand.
I am not angry.
Only have no regrets,
for yourself or me.

Did I tell you often enough
that I love you?
Did I do enough
so that you can survive
on your own?
Did I think too much of myself,
or not enough?
Or of you, or anyone?
If I have wronged you,
please forgive me.
Regret is the stone
that pierces wings
and keeps us from flight.

This is my wish.
Keep me comfortable.
Play Beethoven's seventh,
and Monteverdi's Orfeo--
and don't run after Euridice.
She thought your harp too lovely
for you to hang it up.

Keep me comfortable.
Hold my hands,
stroke my face with callused gentle thumbs.
Tell me goofy jokes
and laugh for me.
Wrap me in blankets
and love.

This is my wish.
Let me go,
but if you can't,
I am a bodhisattva
and will pause on the threshold,
one golden-slippered foot hovering,
listening.
As soon as your cry reaches my heart,
I will turn and fling myself back.
I will not leave until you let me go.

Let me be so selfish
to leave you not with firm desires,
but to allow you all the time you need.

This is my wish:
let me take up residence
in your memory,
and always remember
I am love.

Mythology and Medicine

Since before I began medical school, I have been interested in the two symbols of the profession: the caduceus and the staff of Asclepius.

The caduceus is probably the more familiar symbol: two snakes entwined around a winged staff. Mythologically this is the symbol of Mercury/Hermes, messenger of the gods, and not really a healer. I've heard it is the usual medical symbol because of an on-a-whim decision of a bookbinder to stamp the spines of medical texts with it.

The staff of Asclepius, however, is a single serpent twined around an unwinged staff. It is argued that this is the correct symbol, because Asclepius was a healer, a son of Apollo (who was a healer in his own right), who was advised in healing by a snake, symbol of wisdom. The snake insisted on talking with Asclepius at eye level, so Asclepius held out his staff. The snake climbed it, and the two met face to face.

However, what fascinates me is that Hermes was the god of boundaries, helping travelers have safe journeys. One of his epithets is "Psychopompos," conveyer of souls, a word still used today to describe those who guide the souls of the dead safely to the underworld. Some use this point to argue that the caduceus is a devastatingly wrong symbol for medicine, but I have to disagree. Shouldn't part of all medicine involve guiding the dying to their rest?

For myself, I take them both as valid symbols of the profession.

(And in an interesting footnote, Asclepius was raised by Chiron, a renouned centaur healer, whose name bears an eerie resemblance to Charon.)

Sweet Heaven

"What do you want?" we asked.
"I want to walk into sweet heaven."
She smiled,
hugged her family,
and nodded.
We gave the sleeping medicine.
She closed her eyes,
leaving two orange flowers
to keep unblinking watch
while a tiny chipmunk
scurried across the patio,
carrying away her soul.

No story, no poem can do her justice.
A life fully lived
leaves no scraps for words.
I can only say how
her eyes were sparkling,
her hands warm,
her face bright,
as she stepped out into the sun.

All is well

My patient is dying. Perhaps she is already gone, but she is young and has a strong heart. It could be days... or it could have already happened.

I've seen her for a week and a half, following from hospital to residential hospice-- it just happened that my schedule coincided with hers. I was there when her family said their goodbyes. I got a hug too, and I wanted to hold her hand, to be there with her, to be as comforting as I could... but her family was there, and it was for me to step aside and let them be nearest their loved one, even if their loved one had also become my loved one.

There was one point, after she'd been given medications to make her sleepy and comfortable, where she cracked open an eye and seemed to look at me. "It's ok," I whispered, and she shut her eye again.

Her family shooed me out, but not out of malice. I had been suffering an allergy attack all day, and it was only worsening as time drew on. Ever nurturing, her family told me to go and pick up my new allergy prescription so I didn't suffer so much the next day.

They gave us both permission to go. I wonder if she has yet.

Untitled

She stretches out her arms for a hug.
"I wish I could give you a kiss," she said,
"but this mask..." she tugs at it,
the plastic Clotho on her face.
All the spinning has rubbed raw her nose,
and she is exhausted.
Her son and sister sit in unfailing vigil;
they say all the right things,
tell her not to worry,
it's her choice,
she's in good hands,
we're here for you,
relax and rest,
we love you.
But when she lets go,
to what will they cling?

Rest

"It's all going so fast."
The team congeals around her,
doctors, nurses, therapists,
social workers, chaplains,
and me.
I've been sent along,
the last gelatinous fragment
to see her safely to hospice.

Where once panic had marked her face,
now there is only peace.

Jaundice

With pickled-egg skin and the voice of a muppet, he tells me about his life before. "We took a boat of Holsteins to Japan," he says with a lilt.

It turns out that I've met, at the other hospital, one of the chaplains that he knew for a long time. His faith is very important to him.

When I shake his hand to take my leave, he says in that sing-song voice, "Bless you, little one."

Object

He's forty-six.
Lives in his parents' basement,
plays video games,
has two cats
and a brain tumor.
"Do you remember our medical student?"
my attending asks.
He drinks me in with parched eyes.
"How could I forget that?"
And for once I don't mind.

The Fish

She is drowning in emotion,
an ocean of tears
crashing against her storm-ravaged mind
in foamy laughter.

She gasps and grasps at air,
and all we can do
is hold her hand
until the sea grows still.

Trauma

I have a trauma in my past.

And unless I've singled you out as one of a few trustworthy people, I'll never tell you exactly what it is-- or even anything more than the phrase above. Even if you invite me to speak, I'll quickly defer: "I don't like to talk about it."

I developed PTSD-- post traumatic stress disorder-- and because just one person was good enough to look at what I was suffering, I was diagnosed. But I quickly found that by telling others my story, I opened myself up to withering glances and a glassy-eyed lack of understanding that quickly turned hurtful, even if my listener had no such intentions.

It's quite common for survivors to downplay their own traumas-- so many other people have it so much worse, we think, and all that happened to me was [fill in the blank here]. It could have been [insert worst case scenario here]. But trauma is trauma, and what may devastate one person can have not much effect on another, and vice versa.

But I won't tell you what happened to me until you prove that you're capable of not judging the specifics of the event, but rather its effect.

The people I have been working with have shown this to me-- they take the time to look beyond the surface elements, and gaze deeply into the person's psyche. They speak matter-of-factly about trauma and its effects on those involved, no matter the cause. And for that I am deeply grateful.

For every time they respected another's trauma, they respected mine. Every time they were gentle with another scarred soul, they were gentle with mine.

Palliative care is not only about healing the dying and their families. It is also about healing ourselves.

Chart Rack

Neatly arranged,
each in its slot.
White labels form a picket fence,
straight and orderly.

One post for each patient
whose doctors fight all odds,
never give up, never surrender.

But overnight a faerie hand
has painted one post orange.
It glows, the amber sun of a granted wish:
She is set free into twilight.

Trapped

"I wouldn't be doing this if it weren't for my husband." My patient spoke plainly as her husband looked on. She had long been diagnosed with multiple myeloma, and suffered many complications, including several bouts of graft versus host disease: instead of her body rejecting the transplanted bone marrow, it had rejected her. She had been in the hospital for over a month, and for many days had stated her desire to return home.

Her husband was her biggest cheerleader, unceasingly telling her how strong she was, how much a fighter, that she would bounce right back to normality as soon as they got on top of this or that symptom. Many times she had done just that, but now she was tired.

All I could do was nod sympathetically.

Then the phone rang. Her husband answered, and I leaned over her bed a little more. "It's easy for your family to say they want you to keep fighting," I said, "because they don't have to live it. They're not the ones in your shoes." She nodded, and I felt the beginnings of a bond between us. But it took a distraction for me to feel comfortable affirming her feelings in front of her husband. And if I, the supposedly dispassionate outside observer, couldn't even validate the feelings to him, how could I possibly expect it of my patient?

Family Meeting

I.

He strutted and postured
with a smug smirk on his face.
He was, after all, the only son.
A heady, nauseating mix
of pity and revulsion
with more than a dash of mirrored superiority
hits me in the gut, shooting out
with tingling ice
into my brain and limbs.

His grin said he knew all he needed to know,
and his eyes were shut tight
so he couldn't see all he didn't know.

Filial piety is blind to futility.


II.

"I can't give her more than I gave my mother."
But he's switched the tenses--
his mother is the one still here, still suffering,
still clinging with a thready grasp onto life.

He lives on a stage born of two places:
overwhelming guilt crashes like ocean waves
against a childish urge to throw up his hands
and abnegate responsibility.
I wonder how often he has had to face the fact
that sometimes, he is the responsible one.

He talks of another man for whom he is guardian,
whose wife is clinging to him
but who, he thinks, should be let go.

I want to laugh at the irony.


III.

His face slips a little bit
when he asks what DNR means.
The only son cannot imagine life
without his mother.

But still he signs.

Anger and resentment enter remission.
Pity remains.

A life lived

My patient died.

I just heard by email. He lasted through his birthday, and died on Saturday morning. I'm glad I heard tonight, so I can get over the shock of it before facing everyone tomorrow morning-- so I can have a quiet evening remembering him and what I learned from him, so I'm not in so much of a daze during morning rounds.

I'm glad he's not suffering... but I weep for him, that he longed to live more, to see more people, have more conversations, listen to more music. I weep for his wife, his children, his friends, who have lost such an interesting man. I weep for myself, that I knew him for so short a time. But I'm so glad I stopped by on my way out on Thursday, because though I weep, I have no regrets. Though I didn't say the word "goodbye," I said it with my hug, with my hands, with my eyes.

I'm glad I got to know him a little, that I stopped by and we talked about music, about history, about his life... that I was able to make a difference for him. I can still hear his voice saying to me, as I left, "You were wonderful."

A Passing

Two angels of death, one elder and one younger, trailed behind the family as they took up their vigil at the bedside of the dying man. Yellow raiments cascaded in flowing waves over their white coats, and they held their slender blue hands clasped neatly at their waists. Quiet, placid masks obscured their features. Most of the man's medications had been stopped, allowing his blood pressure to fall, but his heart was strong and kept beating. He had been in a coma for many days, kept alive by numerous medications at ever-increasing doses and a tireless ventilator.

Softly, the two figures glided between the room and the monitors outside, their delicate footfalls weighted with solemnity, their eyes focusing now on the patient, now on the numbers. In time the elder nodded, and the family vacated the room. The curtain was drawn, and the ventilator's steady hum and intermittent whistle fell silent.

The family filed back into the room, stroking the dying man's hands and face. In two minutes, the elder put her ear to the stillness, and, catching the wife's eye, nodded again, her face a mask of perfect calm. The finality of death struck like a silent clap of thunder, and in its wake the wife keened her sorrow.

The younger found she could no longer hold up her mask under the onslaught of wailing, and it crashed to the ground as tears fell from her eyes. She lifted the edge of her yellow robe to wipe at her face in a gesture both coarse and childishly innocent. She managed to adhere to her face again the broken remnants of her mask as the elder led her from the room, leaving the family in the lily hands of the priest.

After the curtain was drawn and the door closed, the elder turned her face to the younger. Her mask had sustained a neat hairline fracture, and fell to the floor as her voice quietly pronounced, in harsh fricative tones, "This is the part that sucks."

Parting

Normally I'd be thrilled to have a three-day weekend. But my patient was still alive when I left today, and chances are he won't be when I arrive at the hospital on Monday morning. "Go home, enjoy your weekend," said my attending. But I had to walk past his room on my way out, and I couldn't leave without saying goodbye...

He asked for apple juice on the rocks, his beverage of choice. It took me two ice machines, but I delivered. Then he confided in me that he was depressed, and wasn't ready to die yet. I held his hand, and we talked about music instead. He loves all the Mozart operas, especially Don Giovanni, and he had a CD player there with a modest selection of music. He was looking forward to his party the next day, to seeing all his family and friends again.

I asked if he did hugs. He said yes, and we embraced. I wished him well, and he told me I'd been wonderful. I told him to get some rest so he'd be strong for the party.

But I just couldn't do it. My voice wouldn't speak that much finality: I left without saying the word "goodbye."

Clinging

"I want to hang on as long as I can," he said, his voice muddled through the oxygen mask. He was afraid to go to sleep in case he didn't wake up again. He was afraid to take morphine in case it made him go to sleep. But he was breathing better now with the little morphine we'd managed to convince him to take overnight.

I held my tears in check. It's easier when they've had time to make their peace with death.

Chills and Warmth

The death hits you, but not like a ton of bricks, like I thought it would. It creeps up softly like a dark cold ocean until you feel it lapping around your ankles, tugging gently at your soul, insistent and subtle. It's rather sobering, especially when you realize you can still feel the warm sunshine on your face as the cold dark water numbs your feet.

We laughed a lot today, more than I would have thought. Perhaps when death is so close, the living cling ever closer to mirth, as if to stave it off.

I'm not sure my patient will make it much longer. I'm not an odds-giving woman, but I suspect his are poor. If he makes it through the night, though, he may last until his birthday on Friday.

Charon's Apprentice

Charon, Vanth, Hermes, Anubis, the Valkyries, the archangel Michael, Anguta... all these and more are my teachers. In nearly every world religion there is a guide for the dead, a being to escort souls to the afterlife. In the realm of mortals, the psychopomps are the palliative care providers, the hospice workers, the physicians and nurses and social workers and chaplains who bear witness to suffering, death, and dying.

For this month I am one of them.