Running into Dissonance and Death in the ICU

I am a runner. I run long to train for iron distance triathlons. I run for fun with friends in the cool early morning sun and for a hot venti americano after. I run to cope with the frustrations that comes with life and being a busy physician in today’s world.

I am a doctor. I take care of the critically ill. I treat patients to try and reverse life-threatening illness. I care for them while on life-supporting machines and medicines. Most of the time they heal and recover. Too frequently they don’t.

Today I am running not to train, for fun or to cope. Today I need to hurt. To feel my calves ache and lungs burn. To take my mind of something far deeper and distressing.

Today is day five of my weeklong call in the Intensive care unit. The mid-April sun has found its way to Chicago. Hard to appreciate when tethered to a climate controlled, sterile hospital environment for a week. But as I finally step outside and into the day’s light, fresh air hits my face, warm and refreshing. Almost liberating. Nice but fleeting. It’s no match for this ache inside.

I grab my running shoes. I want and need to take advantage of this brief respite. The breeze outside guides the few clouds across a pale blue sky. They look light and airy. I want to feel that. Weightless.

I leave the house and start on my path. My brain is firing, full of disjointed, moving thoughts loosely connected by invisible threads:  Truisms, Stages of grief and dying, Geometry, and Laws of nature. They move like frenetic billiard balls, fueled by this internal entropy, bouncing around in my head. I try to stay with one, to try and process, only to have it ricocheted out by another Brownian thought. I need to catch up with newtons first law, and I hope by putting myself into motion, these thoughts might slow down enough to allow me to grab hold.

Mile 1.  At the start of my runs I try and establish a baseline. Cadence, heart rate, pace. The basics. Building blocks. Starting points. I think of the basic rules and truths of my work as a doctor for the critically ill.

Rule 1: People will die in the ICU.

Rule 2: Doctors cannot change rule number 1.

Rule 3: Doctors, can however, impact the pace of rule number 1.

Doctors, along with modern medicine and a functioning healthcare system, can prevent death. We treat acute pneumonias and repair ruptured vessels and perforated organs. We shock defibrillating hearts, stent open blocked vessels and swap healthy organs for those that have failed. But death, ultimately, is not something that can be beaten back or battled and won. It was deemed inevitable the day we were born. As a physician, I have accepted this fact, although admittedly, I am still working on this as a human, a spouse, a parent and son. But even though there are things we cannot fix, repair, or shock back to health, we have the ability to affect the shape and pace of that path forward. To create more opportunities to feel the warmth of the sun without a window in the way, or a mouthful of cold ice cream with hot fudge, dripping from a messy waffle cone, instead of a tiny hospital paper cup. To joke and laugh or argue and cry in the presence of those who mean the most. But if those things that give life meaning are no longer obtainable, then the ability to slow the pace of death becomes less noble and more uncomfortable. I currently have a few patients on service where death is imminent. They will never feel warm sun on their faces, or ice cream on their lips again. And I do not know if their ears still hear the familiar voices of their families at the bedside.

Mile 2. Sweat beads around my visor. The heat counters the cold in my core. I feel, for the moment, a little more in control and grab hold of a thought. There are two points, A and B, in my head. That is where my patients exist. They are at point A, alive but not living, moving towards death, point B. In Euclidean geometry, the shortest distance between two points is a straight line. But distance is not the space where medicine operates. The time and the rate at which we travel are the variables under my influence.

Rate is equal to a change in distance over change in time.

Newton’s second law of motion states that acceleration, a change in rate, is equal to the forces acting upon it multiplied by its mass.

Currently, I am applying forces. I force air into lungs that do not want to open.  I push fluids and medicines to force a heart to beat stronger than it is capable. I am trying to slow acceleration.

From a medical standpoint, there is nothing particularly challenging about those actions. Complexity comes, not from my patients’ physiology but from the denials of their families. As sure as confident as I am that we are headed toward point B, the families are just as certain, if not more so, that there is a different point, with a different letter, that will provide a different outcome. One where my patients will feel the sun on their faces again.

This is where clinical medicine ends and something else begins. I leave my comfortable role as an intensivist, the fixer of electrolytes, the manager of a ventilators, the titrator of pressors, to be something very different.

Mile 3. On some runs, the need to constantly physically push myself fades as I settle into a rhythm. My breathing, swinging arms, and sound of my shoes making contact with crushed gravel all serve as a metronome, freeing more headspace. I visualize the connection between doctors, patients and families. There is a naïve almost quixotic view of how this dynamic should play out in the ICU. We spend more than a decade learning how to help critically ill patients. They come in, burning up with fever, disoriented and altered. They struggle to breathe, their lungs filling with fluid. We diagnose the problem then thoughtfully implement a treatment plan. Their fevers break. Their oxygen levels improve. Their confusion lifts. The angst of their families is relieved. This is the paradigm. We help and heal. We decrease tension and provide comfort to patients and families alike. When we walk into a patients’ rooms it evokes hope and trust from all around.

Unfortunately that has not been my experience this week. My presence, my body and my words bring the reality of death into the room. I discuss persistent fevers, the need for more oxygen and continued confusion. I explain accumulating acids, intolerance to nutrition and the development of blood clots while still being prone to bleeding.  As I explain each failing organ system, an emotional force pushes back, an incoming tide fueled by the strength of decades of marriage, parent-child relationships, and complicated memories.

Newton’s third law of motion states that for every action there is an equal and opposite reaction.  When I push a family by verbalizing the number of days spent on the ventilator or the lethality of a patient’s underlying disease, it will evoke an opposing response that hardens their denial, mistrust, suspicion and fear.

Mile 4. I can feel it a bit in my legs, the build-up of acids. Lactate is being generated faster than my body can clear. But the discomfort is not enough to distract me from what’s gnawing at my core. Something has been eating away at me this past week. Four patients. All similar. All moving slowly on that line between A and B.  Their families all somewhere on the spectrum of denial. Some outright reject the validity of my words. Others fiercely demand we continue on, without hesitancy, without retreat.

My challenge has shifted from correcting my patient’s failing physiology to understanding the complex dynamics and emotional connections between family members. Is the past full of guilt full of apologies thought about but never uttered? Is the present full of the fear of living a life alone? Are words of love on the tip of the tongue, not yet spoken?  We are in an awkward dance through Kubler Ross’s stages of grief. Objective information is refuted and denied. Families bargain for more tests and interventions, sometimes spewing angry words at staff and providers. The path to acceptance, when filled with tremendous emotional pain, is not a road passively travelled. I am no longer a healer of the sick. I am voicing what families do not want to hear and what their hearts do not want to feel. I am now causing their pain.

And each day a little piece of me is breaking inside.

Mile 5. I push forward. Some days I just run without a goal or destination. Some days I have a specific route in mind. A script of sorts that guides my path. My approach to the ICU this week is similarly structured. I am director of a movie in which I also have a leading role. I manage the flow of information. I orchestrate the movement of the team around me.  On morning bedside rounds, I take extra time to share all that we are “doing” in front of a family audience. I explain the results of images or therapies that have failed. I choose my words carefully. They are active, reinforcing action. I repeat the grim impressions made by other consulting doctors in stone-cold objective fashion. My body language is open. My voice is soft. I maintain eye contact. I take a gentle step forward to decrease that space separating us.

It all feels rehearsed. These are words and phrases I have used time and time again. I fight my desire to scream, to shake and to jolt the family into reality. To show how futile the needlesticks, dialysis lines and trips to radiology are. But I keep it all in. The truth is, at this moment, the families hurt far more than the patients. They don’t have narcotics and sedatives infusing through their veins. But in order to stop prolonging death, I will need to inflict more pain on family members who are already suffering. I need to defy Newton’s third law of motion. I need to get the family to trust me more than they trust themselves.

Mile 6. I pick up my pace and increase my effort. I force my legs to move faster. The lactate starts to burn and my muscles tighten. My breathing is deeper, faster. My legs hurt and back is tight. Each breath is less satisfying. I need this. I need to impose something uncomfortable on myself from the outside to drown out the dissonance inside.

I cause pain in others.

I get it. I know I am not the reason behind their life-threatening infection or metastatic cancer or end-stage dementia. I know that someone needs to talk, to explain and to shepherd families through this process.

But it still hurts.

I navigate my patients and their families through some of the most difficult moments in their lives. From the outside, it appears empathic. My words, though truthful and honest, are not “spontaneous” or “organic”. They feel “scripted” and “managed” cultivated from thousands of similar conversations. But random and improvisational conversations are not helpful for families in an ICU. But what is better for them feels less genuine to me.

I have to focus on pushing forward. My legs want to stop, but I won’t let them. The sound of my forced breaths drowns out the dialogue in my head. It overwhelms the hiss of ventilators and caustic beeps from IV machines and soulless monitors. It helps me erase, for at least a short time, the begging eyes of a spouse clinging to hope.

And as everything fades out, a single voice I recognize as my own comes through.

If I orchestrate a family’s march toward death, is there space for true empathy and compassion?

Can empathy be scripted?

If I cause pain, can I still be good?

The dance I share with my patients and families is complex. The intersection of life and death in the ICU is messy, but we cannot shy away from helping families deal with their pain. A managed, orchestrated and self-monitored approach to such conversations is not is not evidence of a lack of empathy. Failing to help families move beyond denial is.

My run is done. My legs and lungs are spent. So are my brain and heart.

I shower, stretch and try to make the shift from hospital to home. Tonight, we are all home and able to have a rare family dinner together. I think about the complex and intersecting threads that connect us. Messy, yet beautiful. I am thankful for what I have.

Later, lying in bed, trying to recharge for tomorrow, I drift in that place somewhere between wake and sleep.  Three more rules float through my head.

Rule 4. There will always be patients moving from A to B.

Rule 5. There will always be families that will struggle with #1

Rule 6. I will continue to wake up and help families navigate this struggle the best way I can.

Guest Post: Control

It is my pleasure to introduce to the readers of Balance, Dr. Rebecca MacDonell-Yilmaz. Becky is a pediatrician out on the East coast who has not only just completed a fellowship in hospice and palliative care medicine, but has just embarked on her third board certification, this time in pediatric hematology and oncology. We connected through social media and over shared themes in our writing. I have read many of her posts on her blog The Growth Curve and wanted to share her work with all of you. I am honored that Becky has offered to post a piece she has written and publish it first on Balance. I could spend some time describing to you all how her story resonates with me, but instead I will let the beauty of her writing speak for itself.  You can follow her on her blog or via Twitter @BeckyMacYil 

Control

By Rebecca MacDonell-Yilmaz

In the afternoon I’m asked to attend an urgent family meeting. I press the resident who has consulted me for details – a middle-aged woman with ailing heart and lungs – and scour the chart to fill in the rest. When she came into the hospital, they asked, inelegantly, “If your heart stops, do you want us to do everything or nothing?” and she chose everything. Never mind that her organs will fail soon, that putting a breathing tube down her throat and hooking her up to a machine is unlikely to lead to any sort of improvement and she will eventually die with the tube in her throat or when her family members make the decision to remove it. She’s deteriorating, and the prospect of intubation is becoming more and more real. Yet she seems to grow less and less sure of what she wants.

I enter the room and heavy conversation is already underway. The resident is explaining that no, she wouldn’t feel pain with the tube because she wouldn’t be awake. But we would also ensure that she wouldn’t feel pain if she chose to forego the tube, to “die a natural death,” as we put it when trying to convey to patients that even our most heroic-appearing interventions – in fact, especially those – are unlikely to bring them back.

She says that she doesn’t want the tube. “I’m tired.” We repeat back to her what we understand her choice to be; she confirms. Her son arrives. He is large – in habitus, tone, voice. He starts yelling immediately. This is the third time (fingers held up for emphasis) that he has been called in to discuss this. And she keeps giving the same answer every time. She wants the tube. She should get the tube.

Two days ago, though, she said she didn’t want it. She decided on comfort only, no more treating, no more fighting. Home with hospice and hopes for a peaceful end. Then he visited and she wanted the tube again, or said she did. And now this conversation that has begun ripping apart the moment he barreled into the room.

We don’t know that she won’t recover, he says – no one can say that for sure. I can say it with high likelihood, I say, with medical experience and knowledge. But anything short of certainty holds no clout. In fact, he points out, we must be asking these questions repeatedly because we don’t like the answers we get. From this point forward, he notes, waving his phone,  he is recording our conversation.

The thing is, if she wants the tube, I want her to have it. It’s not what I would choose, or what I would wish for her – I know what that looks like, that ICU stay, that death. But it’s not my choice to make, it is hers. And whatever she chooses, I want to honor it. But I want it to be truly hers.

More yelling. He knows she’s sick, knows she might not get out of here. But it’s her right to have the tube if she wants it. (And her right, I add – if I can finish, sir – to change her mind.) He doesn’t disagree with this last but wants us to stop asking; she’s tired. We all are. I thank everyone for their time.

Back in my office, it’s dark. I make tea, sigh, stretch, and sit to document my work from the day, my work listening, speaking, trying to hear and to help others be heard.

My pager alarms. She has changed her mind, the resident reports; the whole family has. She is tired. She does not want the tube. She wants a natural death, when death comes. This time they all agree.

On the drive home, with little warning, I begin to scream. It rips up my throat, tearing at my vocal cords. The silence afterwards reverberates, hums, and my muscles relax. I inhale and scream again, the deep breath before it like a silent meditation, the eruption a vehement release. Next comes more tearing. And again the relief.

*                      *                      *

I’m late getting home. My boys need to eat – the youngest to nurse, or to spit pureed foods at me; the oldest demanding waffles and syrup. My husband is on a conference call already so can I please distract them, feed, them, try to keep their voices down?

Attempting to head off the toddler’s impatience, I request his help: can he pull open the frozen packaging? Can he put the waffles on the pan? No, don’t touch the oven – for this part, please just watch.

I’m feeling accomplished with waffles ready, baby happy in highchair, toddler climbing hungrily into his seat. The special fork (the one with rainbow stripes) is ready, syrup is on hand, the prognosis for the evening favorable. I pour generous pools of syrup, slice the waffles into bite-sized pieces, and sink into my seat.

“Move waffles,” my toddler says. Move them? Move them where? “Move waffles.” I don’t understand. Show me; help me; can’t you do it?

The fork is suddenly waving in the air, cutting frustrated arcs. “MOVE! WAFFLES!” I hear the tears welling, the wail erupting, as arms and legs start to fly. Baby is whining, upset at the commotion, and also wanting more puree. The conference call is only a room away and voices continue to rise.

“This is not how we act.” I am seething, though I don’t want to be. I pick him up, move us into the next room where there is space to explode and calm down. I know it’s not the waffles. It’s the communication, the struggle to make his needs and wants known with language that has only just begun to blossom. It’s the control, the need to exert any scrap of ownership and direction over his life. And he’s tired. I’m home late, dinner took too long to even start, his brother needs me as well. And he needs food, sleep, reassurance.

Limbs fly through the air, crashing again and again onto the carpet. He yells and yells, face red, cries lashing out at us all. I sigh, grab the baby from the highchair and pull him onto my lap in the living room, latching him to my breast. It consoles him and he eats hungrily, fussing only when I reach away to pull his brother, who is now simmering, whimpering, to my side. I feel the tension seep out of him as I nestle him close, the molecules of my being reaching out to soak up his unhappiness. The cries die down: his, his brother’s, my own. The three of us exhale as one.

 

Rebecca MacDonnel-Yilmaz can be followed at: The Growth Curve and @BeckyMacYil 

Death, Dissonance and the Doctrine of Double Effect. 

This post was first published on Doximity’s Op-(M)ed “First Stab” Collection on 5/2/18 under the title: Should I Heal or Comfort?

Chicago, in February, was dark and cold. Even more so at 5:00 AM, when scraping ice and snow from my windshield before heading to the hospital. It was my first month as an intern in the ICU and my first day without my senior resident present. Working as a team, getting our patients through the day was challenging. Working alone, I felt overwhelmed. Knowing we planned to remove Mr. Thomas’s breathing tube only added to my angst.

A few days earlier, Mr. Thomas came to the emergency room by ambulance, in severe respiratory distress. In those chaotic first few minutes, the ER doctor intubated Mr. Thomas and put him on a ventilator. As the dust settled, and additional information was Read more

Two Doctors, One Patient, the Chicago Cubs and a Common Goal

This piece was written together with a friend and colleague Chadi Nabhan, an oncologist and current Chief Medical Officer at Cardinal Health. This was originally published here in The Oncologist.  

The crowd erupts with joy, champagne bottles pop open, and everyone around me is stunned. The Chicago Cubs have just won the World Series for the first time in over a century! I heartily share the exhilaration of others in my adopted hometown, but my elation quickly deflates as my mind wanders back to 2013 and to one particular patient with one particular disease, which showed that the doctor-patient relationship is not limited to the oncologist but often involves others.

The oncologist: The oncologist’s schedule can be counted on to be overbooked, busy, and regrettably, dominated by patients with cancers that are rarely curable. It is not surprising that oncologists, myself surely included, yearn to see a lymphoma diagnosis in their crowded roster of patients. For when we see a lymphoma diagnosis, we immediately hope for a curable one, such as large cell lymphoma, for which the odds of a successful treatment are much higher than those of other lymphomas. I was thinking about this when she walked into my office, unabashedly in full Cubs gear, even down to her socks. Her husband was by her side, in a male version of the same outfit. Hardcore Cubs fans who were getting ready for another hopeful season, until the C word struck. Cancer. She had been coughing for few weeks. Ultimately, a chest x-ray was ordered, after antibiotics failed to improve her symptoms. She had a diffuse large B-cell lymphoma (DLBCL) and was only 48 years old. Our visit lasted an hour; we reviewed the data and I ordered additional tests to stage her disease in order to formulate a treatment plan. A few days later, she walked back into my office with her husband by her side. She was wearing the Cubs attire again, head to toe. I was ready to deliver good news of her earlystage disease when she interrupted, “Just tell me I will live until the Cubs win a few World Series.” I smiled in return and countered, “More than a dozen, I hope.” She had early and curable disease—the cure rate can exceed 80%. I happily explained how confident I was about her chances. I recommended chemotherapy and we reviewed possible side effects, along with how we would treat or prevent them. We both agreed against radiotherapy and I ended our conversation by making clear that our goal was to attain a cure with little disruption to her lifestyle, especially because the baseball season was starting. Time passed, and my optimism, and her smiles, dissipated. She developed fevers and chills while on powerful chemotherapy and was so sick, unable even to watch the Cubs on TV. Her DLBCL was not following my plan and proved unrelenting. I diagnosed refractory disease; the synonyms for “refractory” perfectly summed up my patient’s disease: stubborn, recalcitrant, and unmanageable. I was upset, angry, disappointed, and speechless. This was the disease I should have been able to cure; this was the diagnosis that cancer specialists enjoy treating because of its favorable outcomes. As the three of us sat in a quiet exam room, I with the white coat and they with full Cubs regalia, we discussed options. “We still have hope to cure this,” I explained. I recommended a stem cell transplantation, using her own cells. I was steadfast in my optimism and determined to project confidence. When she asked about percentages, I avoided the answer. I advised her to focus on the mission at hand and to ignore statistics that could easily eclipse our hopeful march forward. More chemotherapy, more tests, more visits, as we forged toward a transplant. Her transplant was thankfully without complications; she was discharged 14 days after her stem cells were reinfused. The nurses cheered her as she exited the hospital and headed home. The baseball season was over. The Cubs did not win, but her Cubs hat remained a loyal guardian angel, covering her bald head and emphasizing her resilience as she fought this lymphoma tooth and nail. On day 45 after her stem cell transplant, I saw her back. She was not feeling well; the anxious looks in her and her husband’s eyes stabbed me in the heart. The three of us knew her disease was back—it probably never went away; here we were again. The room was quiet and we started talking options. We talked about doing another transplant, but this time using stem cells from a donor and not her own. We then discussed the inherent risks, clinical trials, and novel therapies. Before decisions could be made, the options vanished, one after another, because her disease was as remorseless as it was tenacious. A few weeks later, I was preparing to leave for the International Congress on Malignant Lymphoma in the morning—a gathering of researchers, scientists, and clinicians where I would be presenting data on large cell lymphoma. I got a page from the intensive care unit (ICU): my patient had just been admitted through the emergency room with severe shortness of breath. Imaging showed her lungs were filled with “something funky.” The resident offered an opinion that infection was likely and that his team would start aggressive antibiotics. He was maintaining hope, just like he was taught in medical school. The ICU team would monitor, as the fear of sepsis was looming. I hung up the phone but could not get back to sleep. As I stared at my bedroom ceiling, my mind was racing, both sickened and infuriated by the irony.

The intensivist: Every other day is an “on-call” day for the critical care team, and today was one of them. Taking admissions for 24 hours in the ICU is a mixed bag. No one wants more work on top of the already challenging cohort of patients on the service, but the opportunity to take care of patients in the midst of critical illness is a privilege. As an intensivist, more often than not, I haven’t met my patients before they are admitted to the ICU. For the doctors who have known them for years, as the internist or specialist caring for their chronic illnesses, trust and comfort has been built up and earned over time. I rarely have that luxury. My access to patients’ worlds is born out of the necessity of their critical illnesses: the onset of something acute or the progression of something more insidious. I get to ask the most personal of questions, place a stethoscope on their chests to listen to their hearts and lungs, palpate their organs to search for pain or tenderness, and put my hand on their skin to feel how strongly or weakly their blood flows. With this privilege of such intimate and personal interaction come amazing opportunities but also heavy responsibilities. To help heal and comfort. To offer hope and calm, amid the fear and angst that come with critical illness. The charge nurse shouted a quick summary, alerting me to a new patient rolling into the ICU. Late 40s, refractory lymphoma, maybe pneumonia, short of breath. Only four pieces of information, but they painted a picture. No positive mental images came to mind. Angst and foreboding filled my chest. A quick scan of the chart, more words and phrases, and the picture went from bad to worse. “Multiple failed rounds of chemotherapy.” “Status post stem cell transplant.” “Progressive lung infiltrates without a clear diagnosis.” “Increased work of breathing and short of breath.” “Unclear” diagnosis. These were not words you wanted in your medical records. I saw the date of her diagnosis and wondered how she and her husband dealt with that blow. Were they overcome with fear and despair? Did they get angry and defiant? Were they united in their reactions? Did they struggle together or separately, lying awake in a darkened bedroom before the light of dawn? I read about the rounds of chemotherapy, but it didn’t tell me about the nausea, the vomiting, the loss of her hair and weight and possibly her sense of self. I saw the date of her relapse. But it didn’t tell me if she took the weight of those words in stride or if they shook her to her core. All told, these words described a young woman who was running out of options and time. I knew this patient, like many with severe illness too early in their lives, had kept hope near her side. Carried it with her through it all. This is the worst part of my job. Along with the opportunity to help and heal, cure and comfort, I have an obligation to explain the painful truth about the limits of what medicine has to offer. The ICU is often a place where patient and doctor, disease and medicine, are all thrust together. Where hope meets reality. Now I needed to go into the room. Knowing everything. Yet knowing nothing.

The oncologist: Before leaving for the airport, I headed to the hospital to visit her. It was early; her eyes were closed; her husband was resting on the bedside couch. I sat down on a chair by her bed, looking at the monitor’s green lines jumping up and down, showing her heart rhythm. The noises from various monitors punctuated my sullen thoughts. She opened her eyes and offered a gentle smile. She said, “I thought you were leaving today.” “Yes, but I wanted to check on you,” I replied. We both knew her current state was not due to infection, even though we held onto this improbable hope. Hope, however, cannot replace reality; her cancer was getting worse and it was winning the battle. We sat in silence. “Are you ready for your presentation?” she inquired. “Yes, but I will be further preparing on my way there,” I replied. “Good luck and be safe,” she said kindly. I had to leave; I stood up and was at a complete loss for words. What could I say? I wanted to wish her a speedy recovery, but knew that wasn’t even an option. I wanted to tell her and her husband that I would see them upon my return. But would I? I knew deep down that I would not and that saying so would be a lie. I struggled to find the right words. I wanted to keep the hope going, but wanted to be realistic. I wanted to wish her luck, but didn’t know where to find luck when you needed it the most. Our journey was ending. I mumbled something as I exited her room. To this day, I can’t even recall what I said.

The intensivist: I saw the oncologist leaving the room. I felt his anguish as we conferred briefly before he had to leave. The reality is that with growing trends toward hospitalists, a majority of admitted patients will be cared for by physicians they have never met, especially during times of significant decompensation in their health. Most oncologists, however, continue to be an exception. Their relationships with patients are forged in the midst of a life-altering event: the diagnosis of a life-threatening illness, when patients are forced to face their own mortality. At a time when a patient is most fearful and vulnerable, the oncologist has the ability and the mandate to help ease fears and provide a path of hope. With trust and a bond earned over weeks and months of therapy, the highs and lows of treatments, and follow-up scans and labs, they move forward with a common mission and purpose. I often admire the powerful and deep relationships oncologists have with their patients. But I do not envy the burden those doctors carry, one of providing and maintaining hope. I walked toward her room, soon to be the newest doctor in her life. In the next few minutes, I had some basic tasks. Establish a physician-patient relationship. Provide or confirm existing information about her disease. And outline the options for care to her family and her. The challenge was to do this while earning immediate trust, being honest and accurate about the severity of her terminal disease, fighting my own human instinct to present things in the most hopeful of terms, and emphasizing possible options without lingering on how few remained. I didn’t want to hurt her any more than the cancer already had. I wanted to be honest without crushing her spirit. This was where hope met reality. How could I do this? I had no script. I headed to her room with a weight on my shoulders. But whatever burden I felt paled in comparison with hers. As I walked into her room, I saw her for the first time. I noticed her shirt, baseball hat, and socks. This was the first thing I learned about her. I knew her heart bled Cubbie blue. I offered my hand and said hello.

REFLECTION: She died during that hospital stay. Although several years have passed, she was one of the first people we thought of when the Cubs won the World Series. The physician-patient relationship is not one sided. Hope, and the comfort it brings our patients, touches our hearts as well. Doctors are not immune to the emotional challenges of recognizing, accepting, and communicating when our shared hope is no longer consistent with reality. For baseball, hope springs eternal. But unlike the Cubs, she did not have the luxury of an endless number of seasons to start over and try again.

Chadi Nabhan can be followed @chadinabhan
Jeremy Topin can  be  followed @jtopinmd