FROM THE COLLECTIONS
> Resident Expert
Here with Me
You can hold on and still let go.
Joanna D'Afflitti, MD, MPH
Some events change your life forever. On February 5, 2006, my 24-year-old cousin was killed in a snowboarding accident. We had grown up like sisters, and her death left me with an irresolvable sadness. Not a day passes without her entering my mind. My son is named after her; I carry her wallet in my white coat pocket; her number remains, unerased, in my cell phone. She is with me as I round on my patients. I channel her perseverance and sense of adventure as I embark upon a challenging procedure or a marathon call shift. More often than not, however, she is with me as I treat patients facing critical illness and death.
Whether it is sudden and unexpected or gradual and well anticipated, the death of a loved one is always devastating. As a physician, my challenge has been to support families through the process of dying while explaining the underlying pathophysiology and helping them to make important end-of-life decisions. Over the past two years I have had the privilege of taking care of a young woman with systemic sclerosis. She was diagnosed after the birth of her daughter, now 5, when her kidneys began to fail and she was hospitalized with scleroderma renal crisis. Her life from then on was punctuated by frequent hospitalizations and dialysis treatments. Several months ago she was admitted again, this time with an infection at the site of her dialysis catheter. In spite of broad-spectrum antibiotics, she became septic. I had to explain to her family that her condition was critical and that this time, she might not survive. Prior to my cousin’s death I would have been terrified of this situation—afraid to be honest and direct, afraid to be in the room with the grief that would inevitably follow. But I was able to stay with the patient’s family, to tell them how hard I knew this must be, and to walk with them as their loved one was wheeled to the intensive care unit, where the following morning she died.
I had another patient, a woman in her 40s, who had reached the end of a long struggle with breast cancer, now metastatic to her lungs and brain. She had failed several trials of chemotherapy, she was in pain, and she struggled to breathe. Her sister, however, was not ready to stop fighting. She wanted to transfer the patient to another hospital, where she could be enrolled in a trial of a new chemotherapy agent. The patient did not want this for herself but was willing to do it if it would help her sister. I had many talks with the sister, all long and circuitous, all coming back to her saying, “I just can’t give up yet.” She wanted to know why this had happened, why the chemotherapy hadn’t worked. I had no good answer for her. I did my best to be caring yet direct, telling her that she was not giving up but rather accepting the end. She did finally make the difficult decision to let her sister go, as she had wanted— comfortably and peacefully with family around her.
As I carry the memory of my cousin with me from room to room, I know she has taught me that death happens, often without any reasonable explanation. More importantly, she has taught me that people can live with the weight of the ensuing sadness. We can carry loss and still go on with our lives. Enduring her death has made me better able to listen to families and be present with them as they face the death of a loved one, to absorb some of their grief without being undone by it. I will probably carry my cousin’s wallet in my pocket until it falls apart, and I may never erase her number from my cell phone. In other ways, she has taught me to let go of the notion that every tragedy has an explanation, and to free myself of the fear that the weight of grief will drown us.
is in her third year of Brown’s general internal medicine residency training program.
Alpert Medical School