Palliative care physician: ‘Healing is possible’ even when cure is not
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CHICAGO — During her fellowship as a palliative care physician, Sunita Puri, MD, met a patient who taught her that healing is possible even when cure is not.
Alice, a 35-year-old woman, had acute myeloid leukemia.
She had undergone multiple lines of treatment — including bone marrow transplant — and now had been admitted to the ICU.
Nobody wanted to say it out loud, but Alice was dying.
“She was only a couple years older than me. She’d lived in San Francisco, a few streets away from where I lived in my residency,” Puri, program director of the hospice and palliative medicine fellowship program at UMass Chan School of Medicine, said during a presentation at ASCO Annual Meeting. “She had a vibrancy that I had always hoped to embody, but she was intubated, wide awake, on dialysis and starting to suffer from ascending paralysis.”
Puri — still at an early stage of her career — judged her effectiveness as a clinician in terms of meeting certain medical endpoints.
“When I was a resident, I measured my self-worth by how many tough diagnoses I made, how quickly I could throw in a line in a critical situation and whether I could ensure that my patients would survive until discharge,” Puri — author of the memoir That Good Night: Life and Medicine in the Eleventh Hour — said during her talk, part of an ASCO education session about finding inspiration in an oncology career. “I deeply valued my relationships with patients, but I saw that as a means to achieving those ends. When I couldn’t achieve those goals, I was floundering. I didn’t know what to do.”
Achieving something meaningful
Cure was “out of the question” for Alice, and discharge from the hospital also looked unlikely, Puri said. Even communication with Alice was a challenge because of intubation, so she and Puri needed to pass notes back and forth.
The case came during an emotionally challenging time in Puri’s training, as she learned patients not only didn’t always survive to discharge, they sometimes died “quite badly.”
“Some people died under other people’s hands getting CPR, and others refused to go on hospice, even though it was clearly the best path forward for them,” Puri said. “Their bad deaths felt like my fault because, once again, I couldn’t achieve the endpoints that I had defined as my responsibility as a palliative care doctor. When these things were out of reach, who was I?”
Although Puri may not have fully known herself, she began to get to know her patient.
As she and Alice scribbled notes, Puri learned about Alice’s family and her fiancé, whose devastation over Alice’s illness prevented him from being able to serve as her medical decision maker. Puri also learned about Alice’s life in San Francisco — the places she and Puri had both visited and enjoyed.
“And yet I felt I wasn’t doing anything for her,” Puri said. “She didn’t have any real symptoms. We were just in goals-of-care discussions with her and her family.”
During rounds one day, Puri told her attending that she was at a loss about how to help Alice and didn’t feel she was doing anything meaningful for her.
“My attending said, ‘What if just being at her bedside is achieving something meaningful?’” Puri recalled. “I’d always understood healing and cure to be different, but this was when I really felt it.”
‘I am ready to fly’
Puri discussed the concept of expansiveness, which gave her a different perspective on the experience of providing care for her patients.
This enabled her to think about healing — distinct from cure — as being an equally important aspect of her job as a palliative care physician.
“What if healing is choosing to understand that there’s going to be suffering that we can’t alleviate — and sometimes that’s our own — but the most important thing to bring to that is presence?” she said.
Puri learned to simply be there with Alice, exchanging notes when she wanted to talk and sitting in silence when she didn’t.
As the days passed, Alice’s ascending paralysis worsened.
In one of their last exchanges, Alice thanked Puri.
“I said to her: ‘I don’t think I did anything, but it’s always been good to be here,’” Puri recalled. “[Alice] smiled and said, ‘You did plenty. You did good.’”
Alice’s last brief but powerful note to Puri read: I am ready to fly.
“I have to believe that healing took place there, even when cure didn’t,” Puri said. “Through the simple act of exchanging scribbled notes on a piece of paper, we found something about our common humanity that we each drew upon to connect more deeply with each other.”
Puri has carried this lesson with her throughout her life and career. She still has moments of self-doubt when she doesn’t achieve specific endpoints, but she reminds herself of the valuable lesson Alice taught her.
“Healing is possible,” Puri said. “It is possible right alongside cure. It is possible for all of us as human beings — and for our patients.”
For more information:
Sunita Puri, MD, can be reached at sunita.puri@gmail.com.
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How we can bring healing even when we cannot cure. Presented at: ASCO Annual Meeting; May 31-June 4, 2024; Chicago.
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