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Comfort care: “We always have something to give”

SMS (“Stanford Medical School”) Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

15952622460_20fb32e76a_z A hospital can be full of discomfort. My patients tell me that the food is unappetizing. The beds hurt their backs. The noise echoing through the hallways at night makes it impossible to sleep. And for those patients near the end of life, the treatments being offered may no longer be of benefit, causing more pain than good.

The answer to discomfort for those who are very ill is comfort care, the use of palliation when life-advancing measures are no longer indicated or desired. These measures include things like giving morphine to dull the pain and ease the breath, applying lip balm over cracked skin, offering ice chips to revive the mouth, adjusting blankets or fans, deciding not to press on someone’s chest, to stifle their airways with tubes, if their status declines. The decision to turn to comfort care often means that a patient can receive a private room in the hospital for family to stay close, to feel sunlight through a window. The triumph of comfort over the many indignities of being away from home.

Death does not need to happen in a hospital, yet too often it happens here. In January, I saw two people die. One was old. He had lived a full life; his room was decorated with photographs from his youth, his tall form in a service uniform, or in a tuxedo on his wedding night, half-cropped face suspended in a laugh.

When I met him, he was on a morphine drip, no longer able to speak. To gauge the adequacy of his pain control, we looked at his heart rate, his blood pressure, scouring for signs of bodily agony. He was tucked into a warming blanket, yellow hospital socks on his feet. Every morning we circled around him, whispering hello into the room where he slept, taking stock of the fluorescent etches of the vital signs monitor, the coolness of his legs.

When he passed, we pronounced him after checking for a pulse and listening for a heartbeat. I felt solemn, but also grateful for his smooth passage.

The second person I saw die was young. She had been full of life and her death ripped up all those who loved her. As she became more ill, and more confused, her family made the brave decision to transition to comfort care. There was nothing gratifying about it, her loss was unspeakable. But perhaps the final moments, free from the blinking of machines, the infusion of drugs that upset her bowels and irritated her veins, carried a dim current of peace.

Not long ago, I lost my grandmother. Towards the end, she had lost control of many functions of her body, and things that previously gave her joy, like biting into a chocolate bar or wearing a freshly pressed sari, no longer seemed to matter. My grandmother grew up during a famine in Bengal. She was strong and dedicated her life to her family. She knew no dreams beyond the balcony of her sixth-floor apartment where the laundry flapped like the wings of a crow. She succumbed early to diabetes, and later dementia. As my grandmother grew sicker, my family in India made the difficult decision to not take her to the hospital.

Her two daughters traveled to join their brother and enjoy her last few hours. Everyone crowded on her teakwood bed where her frail body lay, the same bed she’d slept in since she married my grandfather and moved to Kolkata decades ago. My mother sang old Tagore songs, her sisters held hands. My grandmother’s toenails were painted red. An ayah gently pushed stray hairs away from her forehead. Relatives whispered loving words and memories into her ear, knowing that even if language was lost on her, feeling was not. Then, when her breathing changed, when its stuttering rhythm finally came to a halt, my family gave her a final sip of water and pressed her eyelids shut. Not an easy death, not a death whose pain can be erased. But a comfortable death.

These days on the medicine ward, I often see my grandmother’s face. In a sweet old patient with dementia, who confabulates the most whimsical stories about why she tripped, fell, and came into the hospital. In a homeless man who keeps asking for more trays of food. Or in a grouchy woman whose body has been ravaged by an uncurable cancer, who is convinced that the world is against her. And I have the urge to give her a sip of water. To sit with him. To comb her tangled hair.

Comfort may be the most important thing that physicians can provide through a difficult time or at the end of life. When there is nothing else, or when the other offerings of medicine hurt too much or act too slow, in that moment - in any moment - we always have something to give.

Amrapali Maitra is a fifth-year MD/PhD student working towards a PhD in Anthropology, where she studies domestic violence and women’s health in slums of India. She is currently on clinical rotations. Her interests include global health, primary care, and the intersection of medicine, the humanities, and the social sciences. Amrapali grew up in New Zealand and Houston, Texas, and she studied history and literature as an undergraduate at Harvard.

Photo by Beau Considine

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