Wednesday, November 28, 2007

From tha Annals of Internal Medicine

This is an article which appeared in the latest issue of the Annals of Internal Medicine which I thouhgt you'd like to read.

How Far Along Are You?

took a deep breath befote entering Mrs. Bell's room. I had not yet met this patient, and her nurse told me there were many concerned family members and church friends gathered at the bedside. I knew that Mrs. Bell's adult children were having difficulty coming to terms with the course of their mother's uterine cancer. She was dying, and her family and friends had come to pray and say goodbye. My role as a palliative care fellow was to try to make sure she was comfortable, and to help her loved ones through this time, to the extent they would allow.
I entered the room. All conversation stopped. I felt the eyes of perhaps 20 people on me. I grew increasingly uneasy. I was acutely aware of being the only white person in the room, and I felt all the more conspicuous with my pregnant belly.
"Hello, I'm Dr. Thomas," I said, "I'm from the pain and palliative care team. I'm here to make Mrs. Bell as comfortable as possible, and to answer any questions you might have." Continued silence. I shook hands with Mrs. Bell's 3 children. I went to the bedside, leaned over, and took Mrs. Bell's hand in mine. I smiled at her. "Hello. I heard you were having some pain in your belly. Is it still there?" She kept her eyes closed but held onto my hand and shook her head no. She seemed far away but looked peaceful and comfortable. "Do you know that you have lots of visitors here today? Your children are here, and some of your grandchildren, and your friends from church." She smiled briefly and nodded, keeping her eyes closed. "Is there anything I can do for you at this time, anything to help you be more comfortable?" She shook her head barely perceptibly one last time, and slipped back to sleep. I turned and faced the crowd, "Do you have any questions?"
Someone asked, "What is she getting to help her pain?" I answered, "She has a patch on her skin that gives her a small amount of pain medicine called fentanyl all the time, and we will give her some morphine by vein if she has any more discomfort." A murmur greeted this. "Why is she sleeping so much?" the son asked. "Her body is slowing down. Her kidneys aren't working well and the toxins they usually remove are building up in her blood and making her sleepy. The pain medicines may be making her a little sleepy as well." Again, a murmur arose, and heads nodded as if I had confirmed a hypothesis posed before I got there. Finally, the older daughter gathered the courage to ask the question they were all wondering.
"How much longer does she have?"
I paused. "It's hard to say. Doctors can be really bad at predicting this. I think she will probably pass away in the next few days, but I want to prepare you: I wouldn't be surprised to receive a phone call at any time letting me know she died." There was silence and then again the low murmuring as the crowd processed this. Some looked in

my eyes and nodded slowly, again as if I were confirming what they were already thinking. I asked, "Are there any more questions? Is there anything more I can do for you or for her?" Most continued talking or shook their heads. I turned for the door.
A middle-aged woman in a purple dress approached me. "How far along are you?" she asked.
I paused. "Seven months," I said.
She put her hand on my belly. "Do you know if you're having a boy or a girl?"
"A little boy," I said, unable to keep the delight out of my voice, but unsure it was appropriate under these circumstances. More women joined the conversation.
"Is this your first baby?" asked a younger woman.
"Do you have everything ready at home?"
I smiled and rolled my eyes, "Not even close!" Two more women put their hands on my belly, and they began to pray.
"Lord, please give this nice lady doctor a beautiful baby boy," the woman in the purple dress said in a low, clear voice. "Amen!" arose from the women around me. "Jesus, we ask in your name that her labor be short and the delivery easy!" Again came the chorus of "Amen!" The praying grew in volume and intensity, and calls of "Amen!" erupted at irregular intervals from around the room as more and more people joined in. "Lord, we thank you for the gift of life, for the child you are bringing into the world!" "Amen!"
"Make him strong and healthy, and let him grow up to glorify your name!"
"Amen!" "Amen!" "AMEN!"
I stood quietly in the middle of the circle, with 4 or 5 friendly hands on my belly. Nothing in my career to that point had prepared me for this moment, but I found myself relaxing and enjoying the feeling of connection and support. I felt a deep appreciation that this group saw nothing inconsistent about praying for me and my unborn son in the midst of praying for their dying mother, grandmother, and friend. When the praying quieted down, I shook hands and kissed cheeks all around, gratefully accepting good wishes for the baby. There was an unmistakable feeling that people who had met as strangers were now parting as friends. I left, and smiled as I heard the chatter and laughter follow me down the hall.
Jane deLima Thomas, MD

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