Why Leave Your Heart and Soul at the Door?

By Michael Gordon, MD, MSc, FRCPC

As a tribute to the late National Post journalist Christie Blatchford, Jillian Horton, MD, internist at the University of Manitoba, recounts the humane assistance she received while being, in essence, shunned by the local medical and administrative establishment. This was all while she struggled to get proper care for her sibling who was extremely disabled. In the article, Dr Horton makes the important point that although there was money potentially available for institutional care, this did not seem suitable for her needs, and Dr Horton found it extremely difficult to get assistance from the medical staff responsible for her sister’s care. Finally, it was agreed upon to provide the funds to her for care in a free-standing house where she lived until she died.

In Dr Horton’s article from February 14, 2020, published in the Toronto Star ¹, she notes “surprising things in common” between medicine and journalism. Both professions have life at their center. But in the field of medical education, however, there is a moral question that comes up frequently, and it has to do with boundaries. Here are some questions regarding boundaries that Dr Horton highlighted: “How deeply are you allowed to feel? Can you love? Can you share a meal, or visit a patient at their home, or call to say hello? Are you meant to stay at arm’s length, or is it OK to get enraged, to really give a damn?” The article continues, “Contemporary teaching in medicine has left an entire generation of physicians thinking that being a professional means checking your emotions at the door. Do your job, get in, get out. Take the history, make the diagnosis, and remember the patient is the one with the disease.”

I think Dr Horton has an important point in the gradual shift in medicine where doctors tend to reject deep emotional ties to their patients and are often counseled by their senior colleagues and teachers in order to not “lost their objectivity” as if being objective is the key quality in the practice of exemplary medicine.

I recall a patient experience and the recounting of it at a medical ethics symposium. I described a case in which I was once asked to intervene, or at least give advice. The patient in question was an elderly Hungarian Holocaust survivor with late stage renal insufficiency. I knew her for many years as she initially lived in the retirement home section of the Baycrest Centre.  She had a renal consultation that recommended she undergo renal dialysis, she refused despite all the explanations one could muster to convince her that she would otherwise die. The staff on the unit were distraught that she would refuse such lifesaving treatment, and they asked my assistance because of my role as the Centre’s ethicist and my long-standing knowledge of the patient.

When I went to speak to her in her hospital room, she seemed happy to see me. As I delved into the situation, it was clear that she understood that without the dialysis she would die. I reiterated the explanation of the nephrologist that the treatment itself was not particularly painful and that she could return to the hospital or maybe even the retirement home between treatments. I knew she was very happy with the retirement home and the friends she had made there over the years.

When I asked her why she was refusing she answered, “I have now no one left in the world—only a cousin in Ottawa who is ill and who I will likely never be able to see again although we do talk on the phone—but she is very ill and cannot talk for very long. I am old, [and used the Yiddish term alter zachen (old goods).]”  She continued, “Why should I live?” After a few moments I replied, “for me, I will miss you if you die and world will be a lesser place.” She stared at me and said, “you will miss me, why?” and I answered, “you and I have had some wonderful talks and you have taught me so much about life through your story.” She replied, “really?”

We spoke some more, and I said, “Please try the dialysis for three months. If at the end you are not feeling that you want to continue, I promise you, we will stop it without any hesitation—I promise.”

She thought some more and then said, “you promise I can stop and that you will come and speak to me once awhile?” I agreed and that afternoon arrangements were made for dialysis at a general hospital from where the nephrologist came. The doctor asked me how I managed to convince the patient, and I told her the story. Although she was a bit dumbfounded, she was also pleased.

I would meet that patient from time to time during the four years that she continued her treatments while living in the residence with her friends and neighbors. On one occasion close to the four-year mark she told me she was getting tired of all the back and forth traveling, and I told her I would keep my promise—the request occurred, and her wishes were respected. The dialysis was discontinued, she was admitted to the hospital, and died due to terminal renal failure. When she passed, it was just over four years from the day our conversation took place.

When I have brought this case forward as part of ethics seminars, many in the audience suggested that what I did was “unethical” and that I had overstepped my duties as a doctor. I found that response interesting but not unexpected; the four years of life did not seem to be a reasonable counterbalance to the proposed overstepping my role and being “paternalistic.” The idea of beneficial interjection did not seem to sway many people in the group, however, we explored the ideas about the role of the physician and ideas of boundaries in modern day medicine and contemporary medical ethics.

I shudder to think that a physician would shun extending their empathetic caring and support to save a life, one that still had considerable meaning on the basis of a construct and interpretation of the principles of medical ethics—a process that was developed to help physicians to understand and appreciate their duties as doctors in best interests and within the framework by which we honor our oath (whether formal or otherwise implied) to those we care for.

Dr. Gordon is a geriatrician and ethicist; formally medical director and head of geriatric medicine at the Baycrest Health Science Centre in Toronto. He trained in medicine at the University of St. Andrews in Scotland and in medical ethics at the University of Toronto. He has traveled and lectured widely and is a medical writer having published a number of books the most recent ones being Parenting your Parents: Straight talk about Aging in the Family—co-authored with Bart Mindzenthy. 

Reference:

1. Horton J. What I learned from Christie Blatchford: There is no substitute for giving a damn. The Star. https://www.thestar.com/opinion/contributors/2020/02/14/what-i-learned-from-christie-blatchford-there-is-no-substitute-for-giving-a-damn.html. February 14, 2020.