‘Wear Gratitude Like a Cloak
And It Will Feed Every Corner of Your Life.’

-Rumi

First of all, you should know that I am a very grateful person. Incidentally, as I type this, there are more than 1100 of you in my “Physicians Living Intentionally” group space, and the podcast that I just started a little while ago has been downloaded more than 2600 times, too. Countries all over the world. My heart is thankful.

I am grateful for what you all do. How hard your lives are. With your work as a young physician (the majority of this group is ages 34-44), and a young parent, I know how hard it is to juggle it all. That was the hardest part of my life. I’m here to tell you that it gets easier. Meanwhile, I want you to enjoy the life you have. Mostly, because my terminal patients don’t get a chance to relive their lives, I want us to live a life with intention. So that when our time comes we are much more ready to go.

We all know how it feels not to be appreciated. We have all had bosses who didn’t quite notice all the good we did and all the extra steps we took when no one was watching. It does not feel good.

If I can teach you something today, it’s this: Tell someone you are grateful for them. Even when you are so overworked and stressed that you feel like you have nothing to give. Give them your gratitude. Watch their attitude change toward you. Instantly. This can be your spouse, coworker, children, and of course yourself. A pat on your back is good, too. Do it yourself.

About 6 years ago, I had a consultation in the ER. While I was there a hospitalist was admitting a different patient. He said: Wow, the Creatinine is higher than the BUN! Then he joked,

“Isn’t that a criteria for a palliative care consultation?”

I peaked at the labs. No joke. Bun was 6 and Creatinine was 12. Patient was a 44 year old man. Out of curiosity, I asked what was happening with his patient. He said: ‘multiple myeloma’.

The following day, there was a consultation for us to see that same patient. He was severely septic, thrombocytic and hypoxic. I never did speak to him as he was altered. I met his wife outside his room. We had a long talk. She was about my age and they had two girls about the age of our children. He was an engineer and she was a professor at a local university. She asked me what was going on with him. I did my spiel: We want to hope for the best but also plan for what’s most likely (I never say plan for the worst, death is not the worst to me). She asked me what I thought his chances were. I had to ask: chances for what?

See, I did not think he was going to survive hospitalization, yet she was still hoping for a cure and a full recover.

I said that I worried that his time was very short and she should bring the girls in to see him before he got much worse. She was not sure. She did not want them to see him like this (I somehow understood and agreed with her). We discussed code status. I said that I did not recommend resuscitations should he experience a cardiovascular accident. I recommended no CPR/shock or intubation. I said, as I often do: Should he have a cardiopulmonary arrest, I think we should let him die naturally.

I did not think prolonged hospitalization would ‘bring him back’. Just longer agony for her to decide when to stop the treatment and the guilt of having made that decision. I feel very strongly that as physicians when we know the patient will not survive hospitalization, we should RECOMMEND a DNR status. It should not be a shared decision. Although, if the family would strongly disagree with my recommendations, I will still honor their wishes. But I am clear and firm on my recommendations.

She agreed to his DNR status.

The following morning, I got a 911 page from the intensivist. My favorite saying that no one listens to is this: there are no palliative emergencies. I paged him back. He said, “I think you should come in. Our patient is having non stop epistaxis. He is extanguanating. We can’t keep his pressure up. We called his wife; she’s on her way up here.”

I thought for a second. Trying to picture him in his little room. What do you want me to do, I asked. He said, “Just be here for his wife. She really liked you.” My first thought was: she needs a chaplain and not me right now. I asked him to give him some morphine and ativan for his dyspnea and agitation. Then I walked up to the floor. Slowly. Deliberately slow.

As a palliative care physician I no longer run to coding patients like I did as a hospitalist. As long as their symptoms are controlled, I take my time. I take measured breaths and really center my own head. This would be a tough one. He was going to die. It felt almost too close to home.

I walked into his room. It was a disaster. Blood all over the place and he was actively having blood come out of his nose and his mouth. I put my gloves on. Held his one hand and caressed his forehead with another: “You are going to be ok.” Then the nurse knocked on the door.

“His wife is here, Dr. Michaud.”

The oncology nurse was Alicia. I told her: You’ve got your hands full. It’s like a war zone there.

She understood and walked back in with a new set of sheets, pillows, you name it. She closed the door behind her so the wife couldn’t see the inside.

The wife looked scared but she did not know how bad it was. I looked at her face calmly and said: He is dying right now. You don’t want to see him like this.

She was shocked but she held me tight and started crying. Relentlessly. She would not let go. As if the moment she would let go, I would have to open my mouth and utter more words. Like: He’s dead now.

It felt like an eternity. But I’m sure maybe not even 10 minutes. I pulled back. Wiped her face and said: We are going to keep him comfortable. Let us clean him first.

She went to the bottom of the hall to call her kids.

I went back in to help Alicia. It mattered to me to clean the blood off the walls and floors with her. It was very surreal. It was around Christmas time. There was a CD player playing seasonal music. Christmas church music. Alicia looked like an angel. She truly did.

I felt like I was watching a beautiful movie. A sad movie. But a beautiful one. The ritual of cleaning the room. Wiping the blood off of his face, his hair, his hands. Starting the morphine gtt and watching him slow down his struggles, as Alicia continued the dance of cleaning the room. Fluffing his pillow and ‘gently’ putting his head back on the pillow. We moved him and put new sheets on. I was pretty sure he wasn’t feeling much pain by then.

Alicia opened the blinds. The light hit her on her face just right. Just like an angel. The music kept playing.

Music was still playing. She carefully put away all the bloody sheets so as if hiding the evidence of what had happened and also what was about to happen.

We went out and brought his wife and the young girls in. Same age as my own. Christmas music playing. They were not crying. Just walking in gently as if trying not to wake him. Slowly and respectfully.

He died an hour or two after that.

I felt so much gratitude for Alicia. I know the point of this story may appear to be the man who died and left his young wife and daughters behind. For me, the point of this story is Alicia.

Alicia was working non stop while being full of grace. Wiping the blood off the floor and making sure the patient did not suffer. That his family had the best possible setting to walk into.

What she did that day, from my standpoint, was truly the work of an angel.

Try to appreciate a nurse today. They are the least appreciated people we work with. All the jokes we hear about mean or lazy nurses: I have never met one.

She saw me later that day and said in her last 10 years of practicing as an oncology nurse not a single doctor stuck around to help her care for the dying. They would talk with the family, start the morphine and leave.

I am so glad I helped her. But to be honest, I was doing it for me. I felt like I needed to do ‘something’ for this wife that liked me somehow. I did not feel like I deserved whatever she thought of me.

But somehow, Alicia thought I was doing it for her. Holding space for her…

Our job is to reduce human suffering. This humanity is not only that of our patients. It’s also those of our colleagues. Our nurses. Our oncology nurses. How much they have seen.

Express your gratitude to your nurses today. Help them with what they do. Even if it is just a little bit. It means the world to them. If you can lift the emotional weight of what they do just a little bit, they will be so thankful, you cannot even comprehend.

The craziest thing will happen. You will be happier. I promise you this. I did that day.

So much love to all thousand plus of you.