In some ways, I was expecting some grandiose event, or something at least quasi-divine, to be the impetus for further reflection and thought on my ultimate role in medicine. Instead, something that has stuck with me the most, was my experience on the HEIGHTEN program, in which I was to shadow a nurse on the nephrology unit of the St. Catharines hospital. On my shift, I was to help manage five patients throughout the day, and the management of these patients and their treatment seemed quite rudimentary. And it was, for the first four patients. Everything seemed pretty easy. We would introduce ourselves, give them breakfast, address their concerns, and give them their medication. The final patient, however, was different.
It was immediately apparent that patient X did not want to be there. She was not affable, welcoming or interested in us in the slightest. As we entered, she oriented herself towards us as a sort of reflex to our presence, but as soon as she determined who we were, quickly recoiled back into her original position. Why was she like this? Was she upset, or did she simply not have the energy to greet us? Regardless, the task was simple: serve her breakfast.
We started unpacking the breakfast, which contained yogurt, apple juice, a piece of bread, a few pieces of fruit and coffee. Overall, it honestly didn’t look that bad. We set everything up, gave her a few instructions on some of the potential options she had in how she could eat her food, and left so she could enjoy her breakfast. When we returned shortly thereafter she barely ate or drank anything, and we started to explore why this was the case. Surely she must be hungry, as she had not eaten since yesterday afternoon. So we inquired what was wrong.
“The bread is stale as hell!”
The nurse assured her that this could not be the case, as it was baked this morning.
“The coffee is cold and the fruit tastes bad!”
Once again, the nurse swiftly replied by saying that the coffee was originally hot, but since she had not drank any of it, it has since cooled. We did our best to make any adjustments to her breakfast, such as buttering her bread, and getting her fresh coffee, but this still did not satisfy her. She just seemed incredibly emotionally upset about all of this. It was as if this breakfast was an affront on her as a person. We meant no offense or insult with the food we brought, and it was not poorly received by the other patients, so something else must be bothering her.
Well, something was. The next question and her response moreso, I was not really prepared for. I guess in most casual conversations, there is a logical sequence of events that usually leads to a predictable response. I couldn’t predict what she would say next.
“How many sugars would you like in your coffee?”
“I…. Think…. I … Don’t want to live… anymore…”
The way in which this was said still disturbs me. The pauses in between her words, showing her intractable physical and cognitive limitations, juxtaposed her determination to finish that sentence. It was said out of submission and with complete conviction. This was not something that was just said in frustration either, or in some form of manipulation. This was something that I could feel the patient had thought about extensively, and finally mustered the courage to say aloud. She was sure of this, and I was completely unsure of what to do in this moment.
Should we assure her that better days are coming? I am not so sure that is the case. Moreover, if I was in her situation, I don’t know if I would have completely dissimilar thoughts either. This scared me. What are we truly doing here? How long should we continue to treat this patient and manage her suffering? At some point, her descent into death may become even more unglamorous and undignified. I felt immense shame at even being witness to the patient saying this aloud for the first time. She should be surrounded by family members, friends, people who care about her, not a couple of health care practitioners accosting her with our menial/meaningless demands.
This moment is a constant reminder of how medicine is different than I expected. I went into medicine to be inspired, to find triumph in tragedy, and to make a difference in people’s lives. To me, seeing people in that state, a state of helplessness, makes me feel personally uncomfortable and completely dispirited. This woman will not make a drastic recovery, and her fight has mostly left her. The days she is alive will most likely get worse and worse until she dies. There is no inspiration in seeing someone so battered, and beat down, that they have no will to live anymore. Maybe these situations make me feel inconsequential, or maybe they are even a glimpse into my own mortality? If I was in her situation, would I continue to fight every day? I don’t know if I would, and that is harrowing, to say the least.
Many of us enter our field of work because we are passionate, and we want to make “a difference”. What difference can I make in this instance? Like the new teacher, or policeman, or nurse, we believe that we can change people’s lives for the better, but at some point, we have to acknowledge our limitations. Sometimes, the forces of life are considerably more powerful than our tools to fight them. A family will abuse their child, a person will continue to commit crimes to support their drug addiction, and illness will unremittingly strip people of nearly everything they have. To acknowledge your own limitations in these instances is revelatory, as the limitations of suffering are far less narrow and far less forgiving.
I wish I could conclude this reflection by saying that we had some form of a heart-to-heart discussion in this situation. That I changed her mind, and gave her my support to continue fighting, to persevere, that things would get better. Actually… none of that happened. My response was simple. Simple question, simple answer, right?
“2 sugars, OK.”
Maybe this bothered me the most.