A charge nurse in the hospital where I worked as a palliative-care nurse practitioner approached me, looking concerned.
"Don is in so much pain, but the doctor keeps going," she said. "It's really a shame, what she's doing to him."
Don, age fifty-eight, had been in the hospital for weeks. He was suffering from severe peripheral vascular disease (PVD)--a narrowing of the blood vessels, often of the lower extremities, that can cause painful, incurable leg ulcers and tissue death. He'd already lost one leg, and the other one was in terrible shape.
Don had undergone countless tests and procedures. He might have been a candidate for another amputation, but he also had a cardiac condition, and his heart was too weak to withstand another operation. Nearly everyone involved in Don's care felt that he didn't have much time left.
Nearly everyone that is, except for his vascular surgeon, Dr. Lin, one of the few women on the surgical staff.
I'd never met Dr. Lin; she was fairly new at the hospital, and most of my consults were for older, fragile patients. Day after day, though, I heard complaints about the tortures Don was suffering at her hands--the lack of pain management, the false hopes raised.
"We've asked her to do a hospice consult, but she won't listen," the nurses said angrily. "He's not going to get any better, so why not let him go?"
I emailed Dr. Lin asking if she'd like me to do a pain-management consult. To my surprise, she agreed.
Reviewing Don's records, I saw that he'd been Dr. Lin's patient for several years. His PVD had advanced inexorably despite the trial of various medications and procedures. At several points his body had become badly infected, which had weakened his heart.
I went to see Don. Despite his illness, he looked young for his age as he lay there in the hospital bed, surrounded by his wife, daughters and grandchildren.
"It's true, I'm in a lot of pain," he told me. "But I want to keep fighting this disease. I want to be with my family."
His eyes teared up. "I have everything to live for," he said, looking around at them. "And I don't want to be out of it on account of the sedatives."
I reassured him that we could try to manage his pain in a way that would allow him to keep his mental clarity. Dr. Lin agreed with my recommendations for low-dose opiates and other medications, and I began to follow Don's pain-management protocol.
But of course our efforts made no difference to his prognosis. It was still dire.
One day soon after our talk, Don looked at me with tears in his eyes.
"I know that I'm going to die," he said, sadly. "I don't think there's anything left for me to try."
The thing that troubled him most, he said, was leaving his family. He worried about how they would manage, emotionally and financially.
"I just can't tell you how wonderful Dr. Lin has been," he added. "She's done so much for me; I couldn't have kept going without her."
Later that day, I joined Don and his family to discuss his impending death and his treatment prospects, going forward.
Don's family knew that the end was near; and, like Don, they praised Dr. Lin's efforts to beat his disease. Together, they and Don came to a consensus: he would receive no further treatments, just symptom relief.
I called Dr. Lin.
"First of all," I began, "I want to tell you that Don and his family really appreciate all that you've done. They told me that you've really fought hard for him. It means the world to them that you've been his doctor."
Over the receiver, I heard her begin to cry.
"Thank you for telling me that," she gasped. "I just feel so awful. He's so young....I wish we could fix him."
Hearing her sobs, I realized that her aggressive treatment approach hadn't been heedless or uncaring.
"Try anything, Doc!" Don's family had begged. Desperate to ward off the heartbreaking loss that was looming, she had done as they asked: She'd tried everything in her efforts to save Don's life.
What else could she do? I reflected. She's a surgeon: her job is to "fix" people. Now, with Don so sick, she's probably feeling like a failure. Ironically, on their end, Don and his family don't want to let her down; she's worked so hard....
I told the nurses of the new treatment plan, and of Dr. Lin's anguished response to my words. "Do you think perhaps you were a little hard on her?" I asked gently.
From their expressions, I could tell that they felt touched by Dr. Lin's reaction. As we talked, a consensus emerged that of course physicians and nurses alike feel pain at losing a patient.
"Doctors may feel it a little differently, though," one nurse said, echoing my own thoughts. "For them, the stakes might feel higher, because they're supposed to fix patients."
We agreed that doctors and nurses need to be sensitive to each other's perceptions, roles and expectations when caring for patients--especially when a patient is near death.
It struck me that, ideally, caregiving flows in all directions--not just to our patients but to one another as well. On an emotional level, my physician colleagues need palliative care too, I reflected. What would be it be like if we could treat one another with the same deep compassion that we want to give our patients?
Don died peacefully a few weeks later, surrounded by his family.
About the author:
Peg Ackerman is a nurse practitioner and assistant professor in the graduate nursing department at Salem State University, Salem, MA. At the time of this writing, she was employed as a palliative-care nurse practitioner in a community hospital. She has a lifelong interest in writing and has been published in Pulse, in professional journals and texts and in the Boston Globe. "I have cared for fragile, vulnerable, underserved populations for many years and was inspired to document some of the most moving encounters."