As a Hospice and Palliative Care fellow, my day involves a string of difficult conversations:
Advanced care planning for a young patient with a catastrophic illness at 11 a.m. in step down 11.
Terminal extubation at 1 p.m. when family members arrive for room 679.
Family meeting at 2 p.m. in 2 South’s conference room regarding the grandma’s need (or lack of need) for a feeding tube.
The first weeks of fellowship training will walk you through how to provide information as well as help patients and their loved ones make important decisions. By month two or three, you fall into the habit of having a daily routine balancing life and death. But perhaps the most important lesson during this time period is this: You cannot turn bad news into good news.
After months of this regular schedule, one phone call challenged my newly found composure in navigating the grey waters of severe illness. My first bereavement call started as many others do: I pressed the speaker button and dialed 9, 1, and as my hand moved over the next digits, I reflected the chain of events that lead us to this point.
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I never met Mr. M in person, but I met his mother in the medical wards after she was consulted to my service for not being well. I heard from other clinicians that he was a loving son who spent his days working nearby and religiously visited her from 6 p.m. until 9 p.m.
The first time I called Mr. M, he had never heard about Palliative Care, but he heard that Hospice is, in his words, “where people are sent to die.” Providing him information about our supportive role in his mother’s care, therefore, felt as smooth as my daily drive to the hospital while singing to the radio.
Follow up calls taught me plenty about their relationship and family history. Every two days exactly, we exchanged our understanding of his mother’s progress (or lack thereof). By the second week, his command of gastrointestinal bleeding could make any third-year medical student run for the hills. Nevertheless, each conversation brought up a brand new problem that Mr. M had no mastery over but diligently strived to understand.
Yet, as the medical problems advanced in complexity, despite his level of awareness, despite his understanding that “we all have to go” as he said, he was unable to say the words “D-N-R” or “Hospice”.
That day, I was calling him ahead of our usual two-day itinerary. I had heard a rapid response announced by the overhead speakers at his mother’s room and 30 minutes later, her name was flagged. She was not an inpatient anymore.
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Answering machine: Please leave your message after the tone.
Me: Good afternoon, Mr. M. (I wondered if I should have said “good afternoon”. Or should I have started by expressing my condolences right away? How can we even begin this conversation?)
Answering machine: ...
Me: This is Felix calling to express my deepest sympathy for your loss. (Did it sound scripted? Will he think I am being fake?)
Answering machine: ....
Me: I know how much you loved your mother ... (Who do I think I am to grant validation to their relationship? I should’ve said “love” instead of “loved”.)
Answering machine: ...
Me: ... and I’m really sorry she passed away. I wish we could’ve done better. (Did I just imply that she receiving chest compressions as opposed to dying peacefully is our fault?)
Answering machine: ...
Me: Ehh.
Answering machine: ...
Me: Mmm.
Answering machine: ...
Me: Please don’t hesitate to reach out if there is any way we can help you. (But how could I really help him?)
Often during our training, when patients disappear from our list they also disappear from our thoughts. As clinicians, we tend to forget that most hospital admissions are life-altering events for anyone else involved.
Although my first call was truncated and unilateral, with the insight of social workers and attendings, this newly developed skill of making bereavement calls has shed light to the aftermath that families face after their loved ones pass away. Somehow, calling families to express my heartfelt condolences has provided my career more meaning. I feel closer to becoming the caring physician that I aim to be.
Perhaps one day I will be able to integrate into my practice time for brief calls too: a time to make sure that urinary tract infections didn’t recur, for instance, or a moment to make sure that pain is well-controlled. Or a few minutes to make sure caregivers are coping well.
Felix Reyes, MD finished medical school in his native country of the Dominican Republic and completed an Internal Medicine Residency in Brooklyn. He is currently a Hospice and Palliative Care fellow at Montefiore Medical Center in the Bronx, NY. He has focused his career in improving access to care for vulnerable populations and aims to focus his career at developing population-level interventions to improve health care in Latin America.
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