Dyads in Palliative Care: The Art and Science of What We Do


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This was the keynote presentation I gave at the New Hampshire Hospice and Palliative Care annual meeting.

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  • So… putting people back together is what we do, but how? How do we do this?
  • Dyads in Palliative Care: The Art and Science of What We Do

    1. 1. Dyads in Palliative Care: Balancing the Art & Science of what we do <ul><li>Suzana Makowski, MD MMM FACP </li></ul><ul><li>Director of Palliative Care </li></ul><ul><li>Service & Education – Cancer Center </li></ul><ul><li>University of Massachusetts </li></ul><ul><li>School of Medicine </li></ul>
    2. 2. Basho We shouldn’t abuse God’s creatures. You must reverse your haiku, not: A dragonfly remove its wings - pepper tree, BUT A pepper tree add wings to it - dragonfly.
    3. 3. Dyads Life DEATH Hope Despair Curing healing Art Science
    4. 4. Morning Report: The training ground <ul><li>1 st : How to elicit complaints/symptoms/concerns </li></ul><ul><li>2 nd : How to create a differential diagnosis </li></ul><ul><li>3 rd : How to test/evaluate to narrow down the diagnosis </li></ul><ul><li>4 th : How to treat the disease… </li></ul><ul><li>But… </li></ul>What is next? What happens when this problem can’t be fixed? Science, knowledge is missing…
    5. 5. Bill Sarnoff Board member Bravewell Collaborative <ul><li>“ Nobody treated my wife, but as anything but a disease to be cured... there was no one looking at her as an individual, a person...” </li></ul>
    6. 6. Dr. Robert Martensen <ul><li>“ But when you look at Medicare overall half the money that we spend in this country on Medicare is spent on patients in the last six months of their lives. </li></ul><ul><li>And if we were providing some kind of wonderful existence, then one could make the case but as I have written about and as I certainly experienced, and I gathered you’ve experience and many others, these last six months are not, they’re often agonizing and very unsatisfying for all concerned.” </li></ul>
    7. 7. Mr. & Mrs. Adams
    8. 8. Asphodel, That greeny flower by William Carlos Williams <ul><li>It is difficult </li></ul><ul><li>To get the news from poems </li></ul><ul><li>Yet men die miserably everyday </li></ul><ul><li>For lack </li></ul><ul><li>Of what is found there </li></ul>
    9. 9. Negative Capacity – Dyads - Dissonance <ul><li>Keats: </li></ul><ul><li>The ability to hold and cherish opposites in one’s mind at the same time. </li></ul><ul><li>The ability to live in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason. </li></ul><ul><li>Coulihan: </li></ul><ul><li>If we postpone or ignore care in order to irritably search for additional data, or avoid the patient when we experience uncertainties, then we don’t practice effective medicine. </li></ul>
    10. 10. Dissonance <ul><li>Let me explain dissonance. Dissonance can be described as notes whose frequencies are less than &quot;harmonious” to our ears. </li></ul><ul><li>However, dissonance is a requisite part of most music that we hear, providing it with &quot;tension&quot; that leads to &quot;release. &quot;Without it, we end up with music that tends to command little attention.” </li></ul><ul><li>- Mark Hanson </li></ul>
    11. 13. Michael Kerney: “Being connected... A key to my Survival” JAMA - March 2009 <ul><li>Exquisite empathy </li></ul><ul><li>Self-awareness practices </li></ul><ul><ul><li>Mindfulness </li></ul></ul><ul><ul><li>Reflective writing </li></ul></ul><ul><ul><li>Humanities (music) </li></ul></ul><ul><li>Momentary Surprises </li></ul><ul><li>(video clip 4) </li></ul>
    12. 14. Windows of the Heart: Science as Art Otago Daily Times
    13. 16. Dame Cicely Saunders <ul><li>“You matter because you are you, and you matter to the end of your life. We will do all we can not only to help you die peacefully, but also to live until you die.” </li></ul>
    14. 17. So we are called to dive into the Dissonance of the dyad, The irritable uncertainties Of life – death Science – art Patient – clinician I – Thou But into the dyad we bring to it a third We call that Colleague Spirit Presence Love
    15. 18. Wisdom of community <ul><li>Giving permission </li></ul>
    16. 19. On Breaking Bad News after William Carlos Williams By Emily Ferrara <ul><li>Nourish the subtle body between </li></ul><ul><li>“ I” doctor, and “Thou” patient. </li></ul><ul><li>Tend not to the news—for lack </li></ul><ul><li>of what is found there (men die </li></ul><ul><li>every day)—but to what is found </li></ul><ul><li>between. The unarticulated </li></ul><ul><li>fear, sadness palpable in the deepening </li></ul><ul><li>dark, broken by touch, eyes brimming </li></ul><ul><li>hollyhocks, double-blossomed white </li></ul><ul><li>and multiple magentas take breath </li></ul><ul><li>give life, subtle body, what is found </li></ul><ul><li>is nourished, is all we have. Lean in . </li></ul>Video clip 1