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Student Notebook

Applying the Golden Rule

By Ryan R. Joyce

During my four years at Dartmouth Medical School, I often attended the weekly Catholic services in the chapel at Dartmouth-Hitchcock Medical Center. One weekend, Chaplain Christopher Chukwu gave a homily that fired my interest in palliative medicine. He addressed the question of why God allows human beings to suffer. The answer, he told the congregation, could be seen by comparing a human life to a gold watch. As he stood at the pulpit, he held up his arms and pointed to his wrist. Then, with a broad smile and in his Nigerian accent, he said, "I love life and, boy, I love my gold watch!"

Character: Father Christopher went on to explain that when a human being is born, the newborn infant is like the chunk of gold ore that is mined from the earth: unfinished, untested, raw. It is only through the metaphorical fires of human choices and experiences that we are each transformed from something simple and plain to something of truly divine character. The great variability inherent in people's suffering helps to distinguish us from each other and to forge our individuality.

I was reminded often of Father Christopher's message while I took a palliative-medicine literature elective that included reading patients' and caregivers' personal stories and reflections on dying. As the first person in my extended family to enter a health-care profession, I'm very aware that I will soon be the "family" doctor, regardless of what specialty I choose. I wanted to ensure that I am prepared to deal with acute illnesses as well as the more mundane matters of health care. I signed up for the palliative-care elective to learnmore about death and end-of-life care so that some day I might help my family members maintain their individuality and dignity to the very end.

The elective provided an excellent picture of the finite capacity of modern medicine to prolong life, but also of its ability to treat suffering and pain. Medicine involves not only science but also a bit of art devoted to the healing of the whole human condition. Physical, emotional, and spiritual suffering of all forms must be addressed. Nowhere is this accomplished more dramatically and profoundly than in the field of palliative care.

Finality: As I read the stories, I was struck by the patients' strength, grace, and poise as they were forced to face the pain and finality of life. These were diverse individuals, with very different backgrounds, who were each adjusting to—in the words of DMS palliative- care expert Dr. Ira Byock—"dying well."

At the core of every human life—stretching across geographic, racial, economic, and social divides—lies personal dignity. People's roles within their communities and their families serve as the basis for that dignity. As they near death, they cling to that sense of dignity as they try to do what's important to them, whether it's maintaining a wellgroomed appearance, completing a long-set-aside task, or healing old family rifts. I was struck recently by the story of a 31-year-old mother of three children who was dying of metastatic renal-cell cancer. She refused to take pain medication as long as possible because she didn't want to give up being an active mother and wife for her family. She feared losing her identity and dignity more than she feared suffering from debilitating pain.

To help patients maintain their dignity, physicians must show empathy and put forth every effort to know their patients as individuals. We must understand what's most important to them at that point—what aspect of their life is incomplete and needs to be addressed so as to ease their mental anguish over what they are leaving behind for their loved ones. With the end of life, people's thoughts drift to their final and most important goals. What greater gift can any human being give to other people than to assist them in achieving those dreams? All physicians make the effort to do this, but palliative-care physicians in particular have opportunities, every day, to help patients directly in this way.

Dignity: In addition to my academic work, a recent personal loss has had an impact on my appreciation for palliative medicine. Shortly before I began the palliative-care elective,my father's very healthy 79- year-old mother suffered a massive heart attack and passed away. Although we were shocked by the sudden loss, we knew that she had died exactly as she had always said she wanted to—with dignity and without suffering. My grandmother knew exactly what she wanted in life and faced each challenge head-on, without letting anything get in her way. Having been the primary caregiver for her own mother, she had seen firsthand the trials and suffering associated with being elderly and dying. It was not something she wanted for herself. What a divine gift for us all that she was able to pass on with the same dignity with which she lived.

I amdetermined to help allmy familymembersmaintain that same dignity, especially when they reach the final stages of life. I also now feel better prepared to help my future patients maintain their dignity at life's end. For therein lies a true Golden Rule—treat all patients as you would have the members of your own family treated.

The Student Notebook essay offers insight into the activities or opinions of students and trainees. Joyce, who received his M.D. from Dartmouth just a few weeks before this issue came off the presses, grew up in Topsham, Maine. He did his undergraduate work at the University of Maine, majoring in biology, and in March matched with the residency program in anesthesiology at Tufts's Baystate Medical Center in Springfield, Mass.

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