"where is compassion"

She was dying from day one of hospital admission.Her disease was spreading and no improvement was noted in her condition despite of modern day handy knowledge,men and machines.

Finally family gathered to convey wishes of the person who was getting all sorts of life saving treatments.They disclosed that their loved one never wanted heroic measures and let her die.

While deciding end of life care and measures to keep her comfortable,the notion of compassion was said loudly and silently.The question was raised that since she never wanted all that had been done why delay her death.Each ongoing moment was a disregard to her wishes of dying on her terms.The question was asked,"where is compassion when we delay her death".

To some sitting down,taking time,feeling the love and letting go of the tightly held hand is all part of compassion.

To be honest,in the final analysis we all strive for a decision we can live with comfortably.

"family need your signature right now"

The physician assistant working with me handed over a piece of paper from some bank. She asked me to sign it,“family need your signature right now”.

The patient was an elderly male just admitted to my service with all sorts of brain bleeds, intracranial as well as extra cranial. He was almost unresponsive. I knew medical part but to my surprise instead of patients medical status update I was asked to sign a paper from a bank. I looked at the physician assistant and said, “No”.

How some families move on to daily life businesses in a fast pace in the midst of a bad prognosis is astounding. Not to over analyze, as Freud's saying, “sometimes a cigar is just a cigar”, our paranoia about word ‘family’ sometime make us question sincerity of their actions in the midst of a bad prognosis.

To some a quick acceptance of a bad prognosis is quite unhuman.

The acceptance does not only prove that Darwin was so right about evolution and survival of the fittest but probably also prove that for self perseverance humans have yet to evolve.

"food is a medicine"

She was admitted with multiple medical problems.Failure to thrive was one of those.Eating food was just not her cup of tea.Always critical about food served to her.Sometimes complaining about taste,the way cooked,undercooked,overcooked,too sweet,too salty,no taste and the creative list goes on.The most amazing argument was when she started to say that "she is full".

Over time her sustenance was provided with tube feeding.Since nasogastric tube was cosmetically not favourable to her,she opted for per cutaneous gastrostomy tube.What a choice,we all wondered.The paradox was that she had no reason not to eat food in a normal way.

How someone get so focused on to not to enjoy life's one of simple oral pleasure is a topic for research.The answers can be varied with different reasoning but can it be as simple as declaring food is a medicine !

"may you keep healing"

She was admitted with a large abdominal wound open to external world with surgical stay sutures.She had others problems too,heart,lung,kidneys you name it. She was too complicated to be alive.

The one thing about her though was her amazing attitude.She was pleasant,hopeful,not too much concerned.She was dealing,rather living in her medical conditions,with an understanding.

During course of hospital stay,she got better and better.The failing organs were recovering and her wound was healing.Her wound nurse always saying to her,"may you keep healing"and to us,"treat whole patient not the hole".

How some people keep healing in the midst of difficult odd is fascinating.
To some it might be a matter of faith.To other a matter of luck.

I saw that as a prayer in action !

"no home to go back"

He was a all rounder all his life.That was his claim.The medical conditions he was suffering made us belive in his claim.He was a hand full with daily issues.Almost all consult services were involved in his care.

His other talent was being a non stop talker.The stories of his accomplishments,how he lived his life with fun.All life experiences,free love,making money,trying stuffs and the stories after stories about this beautiful house of his dream where he had invested all of his passions.

He will never be able to return to his home with his condition.That was the reality,some say harsh reality of life.

How some one plan life but miss the part of thinking from the end.This is a history lesson.Most people live in a struggle to achieve.
To some Life is a Lie though fill in with Fun which ends up in a hospital or nursing home bed with no home to go back !

" I want to get married"

She was 20 and beautiful.She had a smiley face with short life expectancy.Everyone knew from beginning but no one want to believe.You have to see her to become an unbeliever.How she can die,the question with unmerciful answer.She was dying,rather fast with cystic fibrosis.

All our efforts were finally failing.I was assigned to discuss end of life with this patient. As I entered her room to tell her about her condition and our thoughts,she looked at me with teary eyes and said",I don't want to die".

The moment was stopped,life frezed.I was with tears in my eyes.I agreed with her that this is not the time to die",but we all will die at some point in time". She agreed and with a smile she said,"I want to get married".

Over next 12 hours she was married to love of her life.

How death takes away a life,it does seem so cruel when we see a random happening.To some it is a path of life, like a passage from here to there.

"gourmet ice chips"

He was admitted confused and remained confused over most of his hospital course. What he had done no one knew. His lungs were failing so was his brain.

One day he was driving a truck, the other day he was laying on beach. He was giving instructions to nurses and getting agitated with questions. Almost all of the time he had no idea about what was going on or what he was talking about.In reality he was laying in hospital bed.

The other day he asked us to eat and drink, When asked what would he like to eat or drink, his answer was, ”gourmet ice chips”.

When someone is confuse and still vocal then realities of every day conscious inhibitions come out in open.This takes us to observe interesting aspects of our mind. To some this altered state of mind is nothing but another experience of mind over matter.

To be honest our mind is totally dependent upon matter, call it gray mater or white mater.No mater,no mind. This is it !

"can I have one cigarette"

She always appeared short of breath,I wondered what was going on with her.I did diagnostic tests one after another.All those tests were pointing to one diagnosis that she might have progression of her prior diagnosis of tracheomalacia.Now bronchomalacia was also added to insult and she was short of breath all the time.Luckily her oxygen saturations were decent while awake,with activity and during sleep.She had a fighting chance.

Every day during medical rounds,she showed her frustration to keep staying in hospital.Every day I explained to her the reason behind keeping her in hospital.

One day she told me that she would like to be discharged in next two days as she had to attend this party.I did not asked the details but it did not worked out as she remained hospitalised due to her shortness of breath.

Finally after few more days of care and a definitive management plan,I was able to talk about a hospital discharge day.

The day of discharge,she asked me one question,"can I have one cigarette a day".I looked at her with a smile,rather in pity,and said,"No".

Why some people knowingly do what is not good for them.I wonder,isn't this just human.

To some their need to ask the question,like she did,is not a simple curiosity.The real question is to ask ourselves,was it just a simple need to tell what her desire was or it was more so a self defence with a powerful validation from her doctor allowing her to smoke one cigarette a day.

I felt for her but I did not fall for her !

"paper cuts"

She was visiting to see a patient.There was something different about her which caught my attention.She was wearing a long flowery dress,and rather awkwardly dark make up and lipstick.She was a pretty girl at some point. In a moment all those thoughts of why,how,may be,definitely came to my mind.Those were thoughts of judgement,when we judge other people and label them.As we say that was the defining moment when we mentally undress other person for one reason or other.

I thought she don't have to show off this much.She walked by me,I kept my thoughts to myself,but I had noticed that her feet were rather swollen and she had a generalised rash.The thoughts which were there a few moments ago transformed into rather a new perspective.She was not what she looked a few moments ago.She was trying to hide disease of her skin,a condition, which I knew,felt like paper cuts.

I understood then something about life.All that dress up and all that make up was the struggle to hide all,hoping to change her skin like a dress.

I wondered then,as I wonder now.How the concept of inner beauty remains so cursory in our world of impressions.Beauty certainly is an interesting contradiction.

I felt for her and I kept her secret.

"losing voice to eat"

He was a patient with a problem with his larynx and he was admitted with a tracheotomy tube.He was getting his nutrition through a nasogastric tube.

I learned quickly during my first interaction with his wife that she was a solid advocate for her husband.As I knew them overtime,though much of a surprise,they were a perfect couple;passive-aggressive-manipulative in the broader scheme of events.

During my daily patients round,I was made aware that they were in the process of making a decision to have his larynx removed surgically so that he can eat.
In essence he was willing to lose his voice box in order to eat and get rid of a feeding tube in his nose.It was known to all that eating,not talking, was his top priority.

How one can negotiate ones own compromise is mind boggling.How some people do it with such a clear mind is so unclear to most of us.They give up one vital function to keep another.This is probably one of the most difficult compromise one has ever to make.The choice made here was the one that he has to live with,a choice of no voice forever,and who knows what will be in store for him in meals !

"losing more than one can"

One day I saw this man smoking outside the designated smoking area on hospital grounds.I was very frustrated as he was smoking in other peoples routine walkway.As I approached closer to him from the parking lot,I recognised him as a hospital patient.He was sitting on a wheel chair and he had no hands and no legs.He had amputations for reasons of poor circulation and he was rehabilitating.

The most interesting aspect was that a woman was helping him to smoke,putting cigarrete to his lips,he was inhaling then she was removing cigarrett from his lips and then he was exhaling smoke from his mouth and nose like a chimmney. What a shocker?

I could not take it,so I went to him and without any reservation I said,"sir this is not good".
He looked at me with a piercing gaze and replied,"what he will going to lose".

How some arguments can reach a dead end is amazingly not so simple.The only thing what made him to say what he said was his total disregard to life,his and others.
He made a selfish argument about himself with total disregard to others. His woman companion who was helping him to smoke and peoples using walkway where he was smoking.He was exposing them with his second handed smoke in the truest sence of words.

To some he may be losing more than he will ever know.Perhaps more than losing his limbs,he was losing respect !

"already accepted that he had died"

She walked in with her portable oxygen tank,upset about not knowing that her husband,who was a patient, went on an appointment at a tertiary care hospital without her knowledge .I explained to her about her husband's serious condition and that the scheduled appointment was a follow up.

I did my part by explaining things in a way to comfort her.She did calmed down.Then she told me that "she had already accepted that he had died before his admission to this hospital".She continued and said,"now what ever is there is OK with her,at least he is alive".

In matter of days and weeks,the patient got better and better.
He was more alert,breathing better,talking with periods of agitation and confusion.Bottom line he was living again and not dead.

One day she asked me,"why her husband is not getting better".I looked at her and reminded her where we started in the beginning.

I wondered then,and I wonder now.How people develop expectations and lose complete perspective.This is an interesting observation which we face daily.

Yes,we can fix curable,but dying with aging and diseased organs is certainly an under reported and virtually unsaid reality.

The biggest challenge is how to convey this to all of us without getting into a confrontation.

"the eagle has landed"

He was disabled from his illness for many years. Now on a ventilator with failing kidneys."I'm going to die, you know", he stated to me in greeting. I wondered was that the declaration or just a reminder."Yes,we all gonna die at some point in time",I replied.

The patient had been quite successful in his life, providing well for himself and his family. He vented his sadness and frustration of slowly losing his capacities over the years, and now being in a failing body of which he had no control. I told him,I thought he was brave to consider things in this way He told me that he was not brave, he was scared, but he was doing it for his wife. "I can't stand to see the pain in her eyes anymore", he explained.

His eyes sparkled as he talked about his "wonderful lady" and "the love of his life", noting how he could no longer be there for her in any substantial way. As I put the phone to his ear. "The eagle has landed", he said to his wife, communicating to her that he had arrived at what would be his final destination here on earth.

How someone can come to such a difficult decision out of love that most of us could not even bring ourselves to think is simply amazing.

I wonder how one can be fearful and brave at the same time.Perhaps being in love makes it easy.

"she wanted to go home"

She had this look of grandmother,and I was her physician.She had her fair share of health related issues,aging was certainly not one of them.She was 91 and she was keep going.

She had bounced back to her baseline after many episodes of pneumonias,urinary tract infections and skin break downs.Even she came off of ventilator to her credit. One of her hallmark was her being a yankee fan in the hardcore redsox nation.

The other day in my daily rounds,I was told that she looked somewhat upset.I tried to ask her few questions,there were limited answers,due to limitations of tracheostomy.Finally,it was narrowed down to one answer as a tear drop rolled down on her cheeks.It was known to all that she wanted to go home.What a heartbreak,as she could not. No one can take her home as her daughter had her own issues.

How this intense desire of going home lives on in some people's mind is truly heart breaking.On one hand their souls are trapped in an aging body which does not want to just give up.On the other hand their mind keep pushing their desire to go home.This might be the struggle of a mind and a soul carried on at the expence of a decaying body.I guess this playground is just way beyond our immagination of living a life as we know.

To some,I wonder,dementia might be a blessing,offcourse in case by case basis !

"from your loving son"

One day I entered this patent's room,his eyes were close,he was coughing with phlegm at the tracheotomy tube,he just needed suction.I did suction and he looked better.His parents were there and they told me," their son had been challenged since birth but he always had the best smile in the whole world".

This was their way of loving,dealing with the ultimate sadness of living through ones child suffering.To be there then and now,to defend and protect their bundle of joy.

I saw a statement on the notice board,and I asked politely,who wrote this;

"#1 dad,from your loving son".His father read with a smile in his voice.
Yes,when we treasure someone our voice has an expression of love,a joy we can't hide.

I knew that patient can't read,write,talk but yes he can communicate in ways only a parent and child can do.If doing so made them happy,I was happy for them.

How some people accept their situations,and struggle at the same time is striking.To some this is the way of living when one is a parent who takes care of a child in the struggle of a life time.

Let's salute to their beautiful hearts.

"let her die"

She was a special patient,an earthquake survivor,now a cardiac arrest survivor with a residual stroke.On a lighter note,what else she needed to prove that she was here to survive,until she had to deal with this tumor in her abdomen which was growing,bleeding and killing her.This tumor was now her survival challenge. As I took care of her,I noticed an enlarging tumor which was bleeding inside and she was dying now.

She was followed up by specialists,who made their final verdict.Let her die comfortably, put her on morphine drip.I had discussions about that and her final preparations with her daughter,who showed her firm belief and faith in God Almighty,and she took it as it was with hope for a miracle.

In matter of days her tumor got complicated with growth which no one can see and the bleeding which everyone can see.Surprisingly she became more interactive with signs of improvement.Then what happened which only happens in movies,a physician offer to intervene and over a matter of days a surgeon agreed to operate and finally removed the tumor.That made her a tumor survivor.

How some people die while other survive is fascinating.Who make those decisions. Whether living or dying is a free will or predestined domain is open for discussion.The concept of code status and subject of comfortably dying looks like all cursory. We relate death with pain.May be it is disease which is painful but death,who knows what it is like to go through except to those dying now and all of us at some point in time,just not yet.

"God's way of her promotion"

As I was discussing the poor prognosis of her husband,who was on a ventilator with high grade fever,I was doing the most difficult task of saying the most unpleasant truth about life.He was dying.The wife took a sigh and said,"do what you can,and I trust you".Then she continued,"for the last many days I am asking God to keep him safe in His Hands,I don't know what to do?"

She told me that when she lost her 6 years old daughter,she could not speak a single word.Now she can and probably this is a God's way of her promotion to deal with this situation.

How do people comprehend God's way of doing things is amazingly insightful.

"she had 18 dolls"

The first time I entered into this patient’s room, I got scared. There was a doll in bed beside her that was starring at me. I could not have eye to eye contact,off course with the doll.

She was a patient who could not breathe,talk without assistance and ambulate so was the doll.Later I was told that she had 18 dolls and the stories at nursing station were as imaginative as nurses from different parts of world.

One day one of her favorite physician assistant visited her, and the very next day to our surprise, like we needed one, there was an additional doll,a black doll was in her bed. It freaked out all of us.

As times goes on, nothing happened and my patient took care of her dolls like a live object. We watched as other patients did, but no one said a single word.

How someone can get so deeply attached to an inanimate object is a question for a curious mind. I wonder that her doll collection was something deeper than we will ever know. It may just be a reminder that we can give meaning to any object of our desire. The more I thought about it,I was not so surprised.

Yes, dolls are part of human tradition whether it is in the form of gods, money, power or our egos. It is just we all have dolls with different faces and different names. To be honest we all do love our dolls.

"broken bones and more"

He broke his ribs, scapula and clavicle while saving a deer on road. That motor cycle accident had taken away a lot from him,including his spleen.

On his first day at the hospital,as I introduced myself to him,he had this look of a hero,70 years old and just too well preserved for his age.

The other day I asked him, why he did so?
His reply was a smile with a sparkle in his eyes. He could not say a word. He had then a tracheotomy and was on a ventilator.

How some people put their lives before their safety to save others is a striking human attribute.It does not matter whether the life they save is a man or an animal. To some this may be the highest calling, a life worth living in and a life worth dying for.

"he is a good man"

I got him as a patient with a challenge.The wife wanted him to get better so that she can take him home.In usual situation it was not a big deal.But in this case,the odds were desperately odd. He was on mechanical ventilator with multitude of problems..

How humans love and keep loving is beyond imagination.
One day she showed me their wedding pictures,nicely saved as a treasure.It was time captured in moments of joy.Sometimes I wish,"lets just freeze in happy times".A smile,cheese,here it is moment.The forever 'aha moment.

Then she kissed her husband,and told me that "he is a good man,he took good care of her when he was healthy".
I saw a glow on her face with a deep shade of sorrow in her eyes.That was love in action:smile,joy,sparkle,tears;all components of being in love.

In the coming days,I saw her involved,caring,maintaining the fine line not to offend egos of doctors and nurses She was there just to have the best out of a sad situation she was in. Every day she had the same goal of taking her husband back to their home. May be some day,but there and then,it was a sad love story.A princess was losing her prince in every passing by moment.

How some people try to make the best out of their worst life situations is really amazing.Can that be a simple blessing or is that a wise choice.What ever is the reason,their ways of dealing with their lives make them living a life full of human experiences.

To some living the fullest human experience is the ultimate spiritual experience of all times.

"he is a broken man"

The other day I went to visit this patient.A very proud,self made,professional gentleman whose pride was a little skewed in terms of having a killer instinct.
He had a stroke which made him dependent on others but I saw enthusiasm of a conqueror in his eyes. I saw struggles.His struggle to survive and learn basic daily living skills and his family's struggle to see this proud man's daily losing battle.

One day his wife told me that a health care provider had made a comment that made her very upset.
"He is a broken man",those were the words.
Those words had echoed day in and day out in her mind.Those were the words which torn apart whatever strength left in this wife to care for a stroke survivor,her husband.

How our words can affect family members is a serious awareness issue in medical community. What we say,how we say,our words make or break people.

Words can have life of there own.Words can cause an invisible sharp razor cut or be an invisible soothing angel touch.The words,verbal or nonverbal, have lasting impact upon the morale and coping of families in a stressful time of their lives.

I wonder when will we treat all our patients like our own parents,brothers, sisters, wives,husbands,children,uncles,aunts and grandparents. Perhaps only then we will mind our own words to heal and keep our words like first do no harm !