hospice (ending)

I just finished my month-long hospice rotation at the Connecticut Hospice in Branford, which both gave more and took more than I anticipated. Perhaps because after a slew of clinical rotations, I've lost a bit of the expectant newness that used to come before each new venture, and so there wasn't much anticipation to begin with. I didn't think much about what hospice would be like before I started. Having had a strong experience that led me to being interested in the rotation in the first place, I think I unconsciously felt that I'd reached a certain level of intensity that would prevent me from being taken by surprise here, even as I approached this rotation as an opportunity for broadening experience, concrete and emotional. I'm glad to have been wrong.

I haven't felt this motivated to write about a medical school experience for a long time, but before doing it in a structured and comprehensive form, it feels nice to sit in bed and ramble about all the things that made it filling, and hard.

On my last day, an APRN asked me what was the most memorable event during the rotation. It would be hard, and probably not accurate, to choose one event or interaction or experience. Instead it was more generalities absorbed that most affected me. I told her that I'd take with me the calmness of the place, the simplicity of the medicine, and the kindness of the people.

Connecticut had the most snow in January on record since years and years ago. We had two two-feet snowstorms, a couple ice storms, and record below freezing temperatures. While I was used to this in Boston where the winter is more harsh than here, I'd never had to deal with the visceral challenges of snow and ice. For the first time in my life, I had to shovel my car out of the snow, had to try to drive it through the narrowly plowed driveway, had to shovel myself out of the driveway that wasn't plowed widely enough, had to shovel piles of snow off the entrance to the street where the tires would just spin in place, had to chip away at inches of ice off every window and off the roof of the car, had to see why getting ice off the roof is important as a I saw sheets of ice slip off cars on the highway, had to steer my car as it slid on unsalted iced roads, had to walk strategically to avoid puddles of slush and piles of iced snow. It was uncomfortable, and tiring to have to work so hard and think so hard about how to simply get somewhere.

There were also incredible vignettes of how pretty harshness can be, in the snowflakes that would freeze on my car windows to create a printed pattern I'd have to scrape away, in the ice that dressed bare tree branches making the forests on my drive looks like crops of glistening gray hair, and in the sheen of clean soft snow hardened on top like creme brulee, by the ice. There were incredible views from the windows, of big flakes falling against warm yellows and cold grays. There were the first falls, untouched, and the old snows, dirtied.

After the trek through all of that, I arrive at a workplace with windows in tandem, bookshelves, and fireplaces. Laid on the beds are crocheted blankets and patchwork quilts. Hand-painted signs of patient's names are hung in their respective spaces. Guitars strum, and every other day there are sweets from families or employees. It seemed to me I was lucky to have done this rotation during the onslaught of winter, to have to confront bitter elements with reason to escape to this cove. It's not often that you think of a workplace as soothing, especially not hospitals.

It's true that this atmosphere is partly due to the way that the rough edges of medicine are worn away a bit by the different goals and mindset of hospice. There is more thought to necessity, and the removal of what's not. In that sense, things feel simpler. There are no fancy tests to order; people often get sicker and instead of embarking on a diagnostic quest for etiology, we acknowledge the worsening condition and continue. There's still a lot of room for creativity in catering to individual needs. My attending pushed us to consider the best options for care, to not get stuck in status quo. But grounding all of that movement is a framework of simple stability. Not to say that dying is simple, but in the face its possible complexities, people's wants and needs become basic and streamlined to the core, without the excess that can often distort. After awhile the pharmacological treatments become routine, leaving more room to focus on non-pharmacological care, and hospice focuses on that much more than other areas of medicine. Its wholistic perception of people is reflected in its interdisciplinary approach to care; doctors aren't at the center, are instead an arm, of the scheme. There is constant, continual communication with the nurses, social workers, pastors, and family. And while there are many factors to consider, the way in which all these people work together to focus on each person's care, gives a simple sense of value.

I imagine that the comforts and simplicity help the staff as much as the patients, because as calming and welcoming a place it is, it is a hard place to be. Because of that, I think it attracts and seeks certain qualities in the people who work there, making for an incredible community. I've never met such a cluster of genuinely warm, kind, and strong people. The nurses, who are the heart of hospice care, made the biggest impression on me, but the kindness is palpable in every person encountered, from the person at the front desk to the person manning the cafeteria.

In the morning, the nurses and physicians round together, going over the care for each patient. The nurses are the ones giving report, which has never been the case for any other rounds I've seen. They make me remember why I want to be good at whatever it is that I do. They take care in the most whole way possible: delicate where people are fragile, tough and honest when needed. They advocate for their patients, they know their stuff, and they all have voice. It's this combination of warmth and strength that I admire most in women who give care, and every day it reinforced goals to work for.

On my last day I told a slightly demented patient of mine that it had been really nice to take care of her. She replied, "It was really nice to take care of you too." Even as her response was a rote one, I appreciate the truth in that. I think that at their worst these patients and their loved ones have given me more than I could give at my best. Each person copes differently, experiences different pains and discomforts. It would be misguided to say that all of them gave the same thing, but as a whole, it was valuable to witness their capacity to give when so much is being taken from them. There is a woman whose body has been distorted and disfigured by tumors, and as she struggles with grace and patience, she makes me think of how deep our reserves run, how much we can face without being torn. There is a man who has accepted that it will be difficult for him to breathe until he no longer has to, and his first thought in conversation is to answer all the questions he knows you'll ask before you ask them, without pause and without rest, with the creases in his face working with effort to give you all he can. There is a man actively dying before the eyes of his wife, who comforts me with stories of him before he was sick--redheaded, singing silly songs in the morning.

In conversation about this, it was pointed out that perhaps it is something about this stage in life, and not something intrinsic to these specific people, that make us that way. It doesn't matter to me too much from where the source stems. To see people in pain, so close to something unknown, be gracious and generous and sensitive gives me faith in the endurance of these qualities and makes me try harder for the patience to endure. And it's not to say that these people weren't struggling, weren't falling back in some ways, but that there seems to be a pull to hang onto the good when things are slipping away.

I can't say that I endured the past month of this rotation with the same kind of grace that I observed in my patients and their families. The rotation was hard for me. I was surprised by how quickly people transitioned from alert to unresponsive, how I could never get used to someone changing so much over hours or days from the way I first met them even for the ones I rationally knew had come to hospice to die. I missed the people they were as they were still breathing, and I wondered how it was for people who had been their lives. While the pace was unhurried and I was never overworked, and I loved most days there, at the end of them I felt tired.

And I was mean when tired, and the emotional stress of seeing and taking in this weighty process manifested in a lot of physical breakdown. Getting sick, breaking out with a cold sore, a couple allergic reactions, and developing various muscle strains, I was told that I was pushing myself too hard, that I needed to listen to my body. I think it is true that we should take care of ourselves, but I also find value in digging for the resilience that lies in vulnerability, and believe that this first means knowing what makes us weak. I didn't plan this of course, and it could be argued that I'm rationalizing the discomforts of the experience. But somehow, an intuitive, inexplicable part of me feels that there is good reason the weather was so harsh, the people so fragile.