Castillo, Maite

Kashan, Sanaz

Minor, Suzanne

DigitalCommons@Florida International University

Florida International UniversityFIU Digital CommonsHWCOM Faculty Publications Herbert Wertheim College of Medicine12-2015A Team Reacts to a Patient’s DeathSuzanne MinorHerbert Wertheim College of Medicine, Florida International University, seminor@fiu.eduSanaz KashanHerbert Wertheim College of Medicine, Florida International University, sanaz.kashan@fiu.eduMaite CastilloHerbert Wertheim College of Medicine, Florida International UniversityFollow this and additional works at: http://digitalcommons.fiu.edu/com_facpubPart of the Medicine and Health Sciences CommonsThis work is brought to you for free and open access by the Herbert Wertheim College of Medicine at FIU Digital Commons. It has been accepted forinclusion in HWCOM Faculty Publications by an authorized administrator of FIU Digital Commons. For more information, please contactdcc@fiu.edu.Recommended CitationMinor, Suzanne; Kashan, Sanaz; and Castillo, Maite, "A Team Reacts to a Patient’s Death" (2015). HWCOM Faculty Publications. 38.http://digitalcommons.fiu.edu/com_facpub/38FAMILY MEDICINE	 VOL.	47,	NO.	10	•	NOVEMBER-DECEMBER	2015 813NARRATIVEESSAYSFrom Florida International University, Miami, FL. A Team Reacts to a Patient’s DeathSuzanne Minor, MD; Sanaz Kashan, MD; Maite Castillo(Fam Med 2015;47(10):813-4.)Ms A joined our Neigh-borhoodHELPTM service learning program from its inception in 2010. She continued re-ceiving care from her primary care physician and oncologist and allowed students and faculty to visit her in the NeighborhoodHELPTM service learning program to provide educa-tion, attend to her social needs, and support her.  Teaching students was important to her; she even chose to continue with the program when her first medical student graduat-ed, though she was losing weight, and her pain was not controlled at that time. An African-American vet-eran and retired postal carrier de-livering mail in Miami’s fierce sun, she eventually succumbed to mel-anoma, which had metastasized to her liver and esophageal nodes de-spite surgery and multiple courses of chemotherapy. She died within weeks of joining hospice in fall 2014. Through NeighborhoodHELPTM, this team grew to know Ms A. Upon her death, each of us reacted uniquely. This narrative strives to describe our reactions and honor this life.  Maite Castillo, Medical StudentI could have never imagined how im-portant Ms A would become to me. She will always be my first patient. I was familiar with her diagnosis and poor prognosis and somewhat naïvely, expected her death as a dis-tant event, without much anxiety or sadness. As anticipated as her death was, it came as a swift, unforgiving, bitter blow. One day, I was support-ing her decision to enter hospice and just like that, she was gone, and there was nothing I could do about it. I had not been able to say good-bye or comfort her face to face. My first reaction of shock, a cold unbe-lieving feeling in the pit of my stom-ach, was replaced by anger and an ongoing sense of cosmic injustice.As days went by, I realized I had been avoiding my feelings and faced them. As I processed them, I resolved that I wanted to practice medicine and care for others as I had for her. She inspired me to become more personable, to put that extra time into learning about patients. Even in her last weeks, Ms A was active in her role as a teacher. She was also always ready to learn, asking me about treatment methods. How could I not admire her? I was awed by this woman who had lived col-orfully and still fought with tenac-ity and kindness. Ms A is and will always be an inspiration to me, an example of the kind of relationship I want to achieve with my future patients. She taught me that med-icine should encompass the physi-cal, mental, and spiritual well-being of patients. Sanaz Kashan, MD NeighborhoodHELPTM Palliative Care PhysicianIt was supposed to be my first vis-it with Ms A. My colleague and I rang the doorbell and heard Spunky barking. We waited several minutes but no answer. Knowing that a few months ago she had fainted in her house, her lack of response wor-ried us: maybe she had fallen down again? What should we do next? While reviewing our options, Ms A’s neighbor approached and told us she was in the hospital again due to in-tractable vomiting and uncontrolled pain; I started getting worried before I’d even met her.I finally encountered Ms A the following week at her home, af-ter several hospitalizations due to uncontrolled symptoms and che-motherapy side effects. Ms A pro-tected her abdomen with her hand in painful distress, saying, “The pain is bad, it used to be better controlled with the fentanyl patch, now that they stopped it I can’t even sleep at night.” I was dismayed when I realized that the hospital had dis-charged her only on a short-acting narcotic, not the fentanyl patch that she needed to control her pain. After several phone calls and a visit by her NARRATIVE ESSAY814 NOVEMBER-DECEMBER 2015 • VOL. 47, NO. 10 FAMILY MEDICINEneighbor to the oncology office that day, Ms A was told by the reception-ist that the doctor did not think fen-tanyl was appropriate for her at this time, and she could continue taking her acetaminophen-hydrocodone as needed. I wrote her a prescription for fentanyl patch. I was angry that the hospitalist and oncologist ignored her words and her pain. Instead they just threw more unnecessary treat-ments at her. I couldn’t help think-ing that if I were not visiting her through NeighborhoodHELPTM she would have suffered in pain for days without appropriate medications.  Robert Buckman, British doctor of medicine and author, wrote, “In gen-eral, the most common problems are caused by relatively simple errors—faults in common courtesy, failures in listening, or in acknowledging the patient’s needs”.1 I was disheartened by my profession; nobody had lis-tened to Ms A.Ms A, with her advanced mela-noma, suffered terribly in the last few months of her life. I deeply re-gretted that her suffering could have been alleviated by simply listening to her distress and being willing to control her pain in an effective man-ner. I hope one day soon we stop the overuse of aggressive treatments for patients who are dying and focus on improving the quality rather than quantity of life. Although her stay in hospice was short, I am glad that we were able to address the psychoso-cial, existential, spiritual, and phys-ical aspects of Ms A’s suffering and bring her some measure of comfort in the last few weeks of her life.Suzanne Minor, MD, Ongoing NeighborhoodHELPTM FacultyWhen I think of Ms A, a few mem-ories strike me. She had started reading the obituaries, and I didn’t understand why this was important to her, but it was. What would hap-pen to Spunky, her German shep-herd mix? She loved telling the story of how he saved her life—after he had knocked her over, he barked until the neighbor came to check on her.  Teaching was also important to Ms A. At the last few student vis-its, I asked if she wanted to remain in the program, because she seemed fatigued. She was adamant. “God wants me to teach these students!” I was impressed with her dedication and  also identified with being com-mitted to something larger than one-self; I had moved to teaching from full-time clinical care to have more service reach. We both needed to pass something on to the next gen-eration.    During our last visit, any move-ment tired her, and she hoped the new chemotherapy would help her fatigue. She couldn’t keep food down. Her oncologist told her the pain couldn’t be controlled. We discussed options.  “What is my responsibility?” Ms A wondered. “Am I supposed to keep fighting, though the cancer’s grow-ing? Or make my peace?” The on-cologist “kept pushing” her about hospice. To her, hospice meant giving up, and she didn’t think God wanted her to give up yet. I, too, have asked these questions often when the pass-ing of a close relative caused me to reassess my life. When should I fight, and when should I yield? What does it mean if I let go of my identity as a fighter? Is letting go its own kind of strength? I am slowly learning that yielding may be a more advanced skill than fighting.  I often felt painfully helpless in the face of Ms A’s advancing can-cer. She rejected hospice for years, unable to accept the idea of giving in. Yet, at the end of each visit, she spoke of how she loved the students coming to see her, and I realized that the visits themselves provided a small diversion and purpose for her. When I phoned and her relative said Ms A had passed, I was heart-broken even though I knew she was dying. Her death brought up death and losses in my life. Grief demands to be felt; there was nothing for it but to cry and feel the heavy sad-ness. I was grateful she found hos-pice and lived with its benefits for the last weeks of her life but lament-ed that it had taken so long.  When I think of Ms A, I bear witness to her feisty, vibrant spirit by teaching well: I hope I role model listening to the patient and supporting and honor-ing her choices.  Ms A’s death affected each of us. In the end, we are just human, with our human emotions and human thoughts. Death affects us all with feelings that must be felt, thoughts that must be worked through. In the busyness of each day, it is restorative to take time to reflect on our feel-ings and write them down. Through reflection, we have moved forward, each in her own way, whether that has meant honoring Ms A, gaining more peace, moving toward closure, or affirming our passion for family medicine and palliative care.  CORRESPONDING AUTHOR: Address corre-spondence to Dr Minor, Florida International University, 11200 SW 8th Street, AHC II, 361A, Miami, FL 33199. 305-798-7954. Fax: 305-348-1495. seminor@fiu.edu.Reference1. Buckman R. How to break bad news. Balti-more: Johns Hopkins University Press, 1992.

A Team Reacts to a Patient’s Death

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