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Lessons in Dying Well

the family was comfortable with these advance directives.

Then, when she was only 64, Virginia Little was diagnosed with metastatic melanoma after she suffered a pathologic fracture—a break caused by illness- induced weakness in a bone. She was admitted to UVM's Fletcher Allen Medical Center in Burlington, Vt., where Katie Little had just entered medical school. Little was able to visit her mother every day. She'd relate what she was learning in medical school, keeping her mother's intellect engaged while she was hospitalized.

Her mother was able to return home briefly, but more complications ensued and she was readmitted to Fletcher Allen. As per her wishes, Virginia Little received comfort measures only, and she died a few days later—the day after Thanksgiving. After graduating frommedical school, Katie Little went on to complete a residency in emergency medicine in 1991. She has worked in the Emergency Department at DHMC ever since. All those hospital visits when her mother was ill don't count as formal training but definitely were part of making Little the physician she is today. "By making the time that fall to be with my mother," Little says, "I think I started to understand some of how patients feel."

One of the things she remembers was how her mother's caregivers talked. "My mother was a smart woman. She and my father were highly educated," Little says. "But they [found it] hard to understand what the medical personnel were saying. For example, I remember my mother saying, 'My doctors tell me that people in my situation have, on average, six months to live. But no one can tell me when the six-month clock started ticking.'"

And Virginia Little had the benefit of not just one but two familymembers in medicine, for one of Katie Little's two

Katie Little's mother was able to return home briefly, but more complications ensued. As per her wishes, Virginia Little received comfort measures only.

brothers is a family physician. Between the two of them, they tried to translate the medical jargon into language their parents could comprehend. Even so, it was hard. "The problem was twofold," Little says. "First was the medical complexity, and then there was the emotional involvement."

Today, Little keeps the lessons she learned back then in mind as she treats patients who come to the DHMC Emergency Department. One of those lessons concerns the value of advance directives. She feels that such documents are "critically helpful, . . . allowing us to navigate the hardest decisions about life and death of a loved one, with the loved one's guidance about their own wishes."

Little also learned during that tough time that "each patient brings his or her own

life perspective" to an encounter with the medical system. For example, social scientists like her parents have "little interest in bodily diseases or mechanics, because their most engrossing thoughts are about political institutions and public policy ramifications." She recognizes, too, that patients' personalities affect the way they approach the end of their lives, "some . . . with dignity, some with anger, some with forgetfulness, some with fear."

Her mother's illness also helped Little appreciate the fact that medicine can seem overwhelmingly technical to patients and their families. She thus knows "how important it is to explain everything in language at their level of comprehension. . . . Patients actually sometimes don't hear more than 10 percent of what their doctors say," she says.

"What my mother's hospitalization and death helped teach me," she concludes, "is about talking with patients and families. It really brought home to me in major fashion that I can reassure patients by speaking in words they understand. I try to take time with each patient, and with their family and friends, to explain as much as I can."

Care is what matters

With remarkable fortitude, Bertha McCullough fought her way back fromseveral health crises when she was in her eighties. She worked resolutely to rehabilitate herself after each setback so she could return to her own apartment in a senior housing community, where she was surrounded by friends and neighbors who looked in on her. But her health problems continued tomount, and she lost the ability to walk. That necessitated a move into a nursing home, where she slowed down still more. One year, as December approached, she told her son she didn't think she'd make it to Christmas. "I just pray I'll die at night," he recalls her saying. She lost interest in

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