At the heart of underusing palliative care is that no person wants to inflict sadness on another.
Among the synonyms for the adjective ‘brutal’ are cruel, barbarous, callous, heartless, ruthless, and merciless. No one, especially not physicians who are dedicating their lives to relieving sufferings of others, would countenance having any of these adjectives attached to their actions.
A doctor’s personal repertoire of adjectives for their deeds would rather include kind, caring, compassionate, self-sacrificing, merciful, and heartfelt. These adjectives would indeed describe almost all their actions. Physician’s acts of commission are suffused with caring and its family of synonyms. Their brutal mob of attributes inhabits their acts of omission – their act of underusing palliative care for those suffering in their charge.
Allowing a patient’s life to run out without comforting their suffering, without palliative care is a brutal act. This is a brutality that is endured not just by a suffering patient alone. Their anguish is radioactive affecting every loved one and caregiver around them. The neglect of using palliative care to relieve the misery of the sick traumatizes everyone in the medical care world of the very ill. The failure by physicians to consider comfort as ‘medical care’ results in a brutal fallout that afflicts every person ministering to the patient’s needs. This brutal fallout has a name: it is called “burnout.”
Burnout is a widely recognized problem for caregivers – loved ones and professional ones alike. It takes little empathy to imagine the harrowing heartache of watching a loved one abiding in unpalliated suffering. Less appreciated is the distressing disquietude experienced by nurses and physicians caring for those patients who have been reduced to paying rent for their lives with suffering to the disease that has mastered their bodies. It is a piteous pain to see a patient’s death approaching when they have not been told it is coming.
There are unavoidable and necessary therapeutic traumas that we inflict in medicine that can make the ‘burnout’ burn hotter when their use is avoidable and unnecessarily. Among the most merciless, purposeless trauma is futile CPR – not CPR that fails – but CPR that never had any hope of achieving anything other than a violent death or prolonged suffering. An acknowledged cause of PTSD among nurses is the dread of performing hopeless CPR on hopeless patients and then enduring the most dreadful of all – having to actually perform it.
Unsuccessful CPR on patients with lives ahead of them is a poignant pain that is inherent in the practice medicine – it is a pain that cannot be evaded. It is the human cost of caring for mortal humans. But CPR on patients whose lives are behind them needlessly breaks the hearts and scars the spirits of nurses and doctors. These can be breaks that do not heal and scars that do not fade.
No doctor deliberately brutalizes a patient, but doctors are inadvertently callous by failing to understand that the palliation of the emotional and physical woes of disease is their obligation just as much as the medication of the emotional and physical tribulations of sickness. There may be as many reasons for failing to comfort as there are physicians but there may be a simple human reason at the heart of underusing palliative care: no person wants to inflict sadness on another. This is a most distressing thing to have to do. There is a private pain at the heart of this failing in the profession of medicine: it is the painfully woeful task of telling someone that the person they love and did not expect to die – is dead. This is an awful agony both to hear and to speak. It is a truly fearful thing to have as a responsibility.
Fears by their nature terrorize our hearts and minds. We all live in fear of our fears. While this sounds simplistic it has complicated consequences: doctors can become afraid of giving bad news, of giving news they think will hurt, of giving news that they fear will be brutal. So many don’t give it but in doing so they are cruel not only to their patients but to themselves. In denying comfort to their patients, they deny themselves the fulfillment of alleviating the suffering of another.
Medicine is not only about saving the living from dying, it is also about saving the dying from despairing. Physicians have great powers that can only sometimes heal but that can always comfort. To alleviate another’s torment when it is possible is truly heartfelt. To fail to relieve suffering when it is possible is actually heartless. It is a brutality when a patient who has been conquered by their disease is denied comfort by a doctor who has been mastered by their fears.
There is a desperate need for more palliative care to end this brutality endured by the sick, their loved ones, their nurses, and their physicians. Palliative care is also, like anguish, radioactive but it causes a palliative fallout which doesn’t hurt but heals all it falls on. Palliative fallout is a balm for the burnout this brutality engenders and we urgently need much, much more of it to fall everywhere in medical care.
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