It was in residency that I discovered I had a gift for having those difficult conversations with patients and families at the medically frail. My firs encounter with end of life care was when I was on weekend call in the hospital on the medical floor. A middle-aged woman, severely undernourished, had been admitted with ALS (amyotrophic lateral sclerosis or Lou Gehrig's Disease). She had dysphagia (trouble swallowing) and was having more and more trouble breathing. The patient was clearly dying and she was cognitively intact. Her daughters had gathered around. Everyone knew and had accepted that this was the end.
No one had trained me for such a situation. Indeed, no one was really trained in end of life care at that point. This was before Palliative Care, a discipline which seeks to provide patients with relief from symptoms, pain, and stress, was a specialty and I had no idea what I was doing at first. It took courage in the middle of the night to turn up the morphine drip to ease the patient's breathing as her swallowing failed and she could no longer clear her airway of saliva.
It took courage to go in and talk to this woman’s daughters about what was happening and why. I found that I was quickly able in such situations to assess the needs of the patient, as well as the needs of the family, and to honor their desires as they navigated difficult illnesses, whether the patient was close to the end or not. I was good at explaining the benefits and burdens of proposed therapies. I was good at helping people die a better death, and to enjoy as much of life as possible in the meantime.
My first work out of residency was running a solo family practice office and in that capacity I very much missed the challenges of taking care of patients at the end of life. I am so glad that the last decade has allowed me to focus more completely on this most satisfying work.
I have to come to see palliative care as a very high calling, an extension of my commitment to providing the best primary care.