NOTE: Posts and comments on The Good Death Society Blog are the views of the respective writers and do not necessarily reflect the views or positions of Final Exit Network, its board, or volunteers.

(Dr. Pujari is a board-certified hospice and palliative medicine physician, practicing full-time for over a decade and currently the medical director for Longleaf Hospice. She is Mayo Clinic-trained in internal medicine, and also certified as a hospice medical director. Her website, The Palliative Post, is a “resource for all things palliative, every spiritual, physical, metaphysical, emotional, mental, and medical aspect of what death inspires us to think, feel, and do.” These articles, used with permission, appeared online at The Palliative Post.)

==============================================

Giving Up

 I am an optimist. I want my patients to have hope; I want to help them keep hope. And when I see a patient who has the potential to stabilize, to even somewhat turn things around for a period of time or longer, I want that for them.

Being palliative for me does not mean turning everything off. Rather, it means doing everything possible to make decline as bearable as possible, to give as much quality to living for as long as possible. If we are able to get more living out of this process, then that is wonderful. And with the nature of mortality changing rapidly in these medically dynamic times – where a quiet but burgeoning revolution in the utilization of our own immunities to treat what befalls us is occurring – it is key to remain flexible in our notions of terminality.

This is why it hurts me to see a patient give up. It’s not always clear why this is occurring. We don’t live in our patients’ bodies; we haven’t walked in their shoes. We will never quite be able to comprehend how hard it is to suffer endlessly over years.

But, when they have been suffering without cease, and come into my world, and I see that there are novel things which can be done to modify the trajectory, to ease the burden, to shift the course, I admit it is painful to have to acquiesce to their decision of doing no more – of letting go.

I can’t help but feel a sad defeat, wanting to give them my mindset of hope and optimism, wanting to be able to trigger a new internal blossoming of faith.

Sometimes, in spite of what we know we can do, in spite of where we know we can go, we simply have to accept the fact that people are tired and worn out from their illness. Patients, over years of dealing with practically insurmountable difficulties, can become so demoralized and robbed of hope, they simply know they want it all to end. This cumulative yet rational end-point of giving up, while very difficult to accept, is sometimes where the patient realistically is, and I respect that, too.

While I want to give my all to my patients, I know that I must meet them where they are. When they have fought the fight they’ve wanted to fight, I will honor their desire to let go, and make sure they have the comfort they were always seeking. No matter how much it grieves me.

==============================================

Dying vs. Dying Well

It’s not always easy to know if you’re doing the right thing. When you’re medicating at the end of life, you hope that what you are doing, medicating aggressively to achieve symptom control, is not only for the benefit of those watching the dying process, but also truly for the patient. Because when a patient is transitioning, they alone are in a unique tunnel of transition, the spiritual passage to another realm, and they are no longer conversational and interactive to give feedback on the big-picture meaning of the intervention.

So, one hopes that medicating as we do is the right thing in terms of the spiritual need. For, irrespective of whether a patient receives medication or not, they will still pass away – not well in our eyes, but nonetheless pass away. With this question of the big-picture utility of medicating, I ask myself in a devil’s advocate fashion what the worth of medicating is. And every now and again, I get a beautiful answer.

I manage all levels of symptoms all the time, but this case was unique in its stark visible reminder to me that medicating can truly be the panacea needed to melt existential suffering. Our patient had advanced cancer, metastasized throughout his body with tumors along his spine. We tried a very strong, non-drip regimen, which just wasn’t cutting it. Despite the strong measure, the patient was gripping the side rails of his hospital bed to bolster himself to remain in a fixed, motionless position on his side, such pain as he was in. His head was tucked down in an unnatural position, because anything less was unbearable.

We started the drip, adjusted his global regimen, titrated everything to comfort, and suddenly a miracle appeared. He went from trying to stay as still in his unnatural position as possible, to resting comfortably on his back. After weeks of endless suffering, he was finally all right. He passed peacefully with the drip.

When one sees the change from pain to peace, from suffering to solace, from bracing to acceptance, one knows that hospice work might just be God’s work. One can question at times if what one does is right in the spiritual scheme of things, but relieving suffering, at least in this realm – the material one – is a glorious thing. It is these eyewitness experiences that shape us and give us the faith that what we are doing might just be right in the big picture.

One hopes so, as there is nothing more rewarding than seeing suffering dissipate.

(Please scroll down to comment.)


Final Exit Network (FEN) is a network of dedicated professionals and caring, trained volunteers who support mentally competent adults as they navigate their end-of-life journey. Established in 2004, FEN seeks to educate qualified individuals in practical, peaceful ways to end their lives, offer a compassionate bedside presence and defend a person’s right to choose. For more information, go to www.finalexitnetwork.org.

Payments and donations are tax deductible to the full extent allowed by law. Final Exit Network is a 501(c)3 nonprofit organization.


Enter your email address to receive these posts in your inbox each week:

Author Monisha Pujari, MD

More posts by Monisha Pujari, MD

Join the discussion 5 Comments

  • LindaJ says:

    As a partner to someone living with a terminal diagnosis, this phrase “but relieving suffering, at least in this realm – the material one – is a glorious thing” was very comforting. We’re okay for now, but the future is an unknown. I hope someone with your understanding is around if and when our time comes.

  • Ron Kokish says:

    Why did you wait so long to start the f-ing drip?

  • Gary Wederspahn says:

    Inevitably, the dying person’s caregivers and loved ones become emotionally impacted. I believe this is natural and good as it triggers compassion and caring. However, they need to give priority to the emotional needs of person dying, while taking care of their own. This is challenging but essential.

  • James T Allen says:

    I very much appreciate your thoughts, but one thing you wrote troubles me:

    “One can question at times if what one does is right in the spiritual scheme of things,”

    Really? I would hope that the only thing to consider would be how to lessen the suffering and anguish of your patients.

  • GARY WEDERSPAHN says:

    The Good Death Society Blog is a “big tent” with space for readers and writers with different religious and philosophical beliefs. We share a concern for the whole person and that includes “spiritual” orientations when relevant.

Leave a Reply