In 2021, the renowned New York Zen Center for Contemplative Care launched the Contemplative Medicine Fellowship, a 12-month training for physicians, advanced practice registered nurses and physician assistants, designed to immerse participants in the alleviation of suffering while supporting clinic responsibilities.
The following editorial, which first appeared in the international journal Palliative & Supportive Care, was sent to us by integrative doctor Tieraona Low Dog, MD and written by fellowship graduate Deirdre Pachman, MD.
“In a profession that rewards doing, it is so very hard to just be.”— Deirdre Pachman, MD
I sat next to her hospital bed in her apartment, holding her hand in the quiet of the evening hours. She had been in bed now for five days, unresponsive. Before being placed in bed with the assistance of the hospice nurses, she asked me if one more bite of oatmeal would help her live longer. These were her last words to me. Previously, a vibrant 70-year-old woman, she became frail and was teetering on her last breath as the cancer continued to grow. I watched her irregular breathing and occasional grimaces; I felt a sense of helplessness and deep sadness. We were on a schedule alternating methadone, hydromorphone and haloperidol. I made sure I didn’t miss giving a dose because I was determined that she would not suffer any more.
I think back on all the suffering she endured in the past year: 10 cycles of intense chemotherapy, a Whipple surgery, multiple hospitalizations and procedures, as well as severe pain, nausea and fatigue. However, her physical suffering paled in comparison to the emotional and existential suffering I witnessed – the regrets, the fear, the anger, the grasping to life, the sadness and loss, and the intense grief of facing death too early.
I am a palliative care physician. I had witnessed the dying process multiple times before. I have cared for hundreds of patients at end of life, but this time it was different. This time it was my mother.
I was called to palliative care because I was called to the intimacy and wonder of end of life. I don’t know if that was from curiosity or fear. Like the saying goes, keep your friends close and your enemies closer. Maybe if I worked with death each day, my fear of it would subside. I was drawn to being with suffering because I wanted to fix it.
In palliative care, we care for those who suffer at the most vulnerable and difficult times of their lives. We are expected to provide relief from symptoms and the distress associated with illness. We may not be able to cure, but we should be able to relieve their suffering. Our training tries to give us tools to do this; we are taught communication skills, how to build rapport and how to name emotions. We are taught how to skillfully navigate difficult and emotionally intense conversations with our patients and their families.
But how often are we taught that really, we cannot fix the suffering of our patients? I know I had heard that occasionally through my training, but this did not help when I sat with a young man with metastatic cancer who was crying when thinking about how his two-year-old will not remember him, or when I was with the young woman who will not watch her daughter graduate high school.
No matter what I have been told, every part of me wants to fix that suffering. I want to take away that pain, grief, loss, sadness and fear – just like I wanted to do for my mother. I tried setting my mother up with a counselor, with legacy work, with integrative medicine, everything I could think of to fix this intolerable suffering. Similarly with my patients, I offered medications, psychotherapy and mindfulness. I was constantly searching for the missing tool I could use to ease their suffering.
While all these techniques helped to an extent, what I have learned through experience and training in contemplative medicine is that there is no intervention I can offer to take away all the suffering.
The first noble truth in Buddhism is that everyone suffers. For so long I felt that the suffering I witnessed in my patients was what real suffering looked like – the physical suffering of metastatic disease, the emotional suffering of losing a child, the existential suffering of facing death. I often told myself that I did not suffer like this, so I did not suffer. I needed to always be grateful for what I have, for my health, for my profession and for my family.
But through contemplative practice, I was able to see more clearly that all of us suffer; it is an innate human commonality we share. When I sit with my patients who carry such intense sadness, I realize that I suffer too. I suffer when I feel like there is nothing I can do to fix their grief. I suffer when I give all my compassion and emotional energy at work and have none left for my family. I suffer when I fear that I too will end up like my patients, dying too young with unfinished life tasks. I suffer when I feel like what I can do is not enough. Suffering is not a competition, and I no longer compare one suffering to another.
I had often heard that our role in palliative care is to sit with suffering, to bear witness. But it has been so important for me to realize that the suffering in front of me is not mine. I did not cause it, and I cannot fix it.
While I can optimize management of my patients’ physical and emotional symptoms, a level of suffering will continue no matter how skillful my communication or how expert I am in the protocol to manage distress. The person in front of me is human, and suffering is a human experience.
This understanding gives me the freedom to sit with and to come alongside the patient — not worrying about the next words I say or what medication I should prescribe — just being present with openness, curiosity and loving kindness.
In a profession that rewards doing, it is so very hard to just be. I still want to do for my patients, and I must have constant reminders that being is OK; being is enough. Authentic, wholehearted being is always what I can bring, regardless of which other medical interventions I may be able to offer.
But just as important is the ability to let this go and not continue to carry others’ suffering, as the weight of this is too heavy to bear.
Despite the challenges, working with these patients and their families is a gift. Being with suffering teaches us the preciousness of life. It teaches us about the beauty of relationship and the rawness of emotion. It teaches us that we do have this one precious life and that we must awaken to our full potential; not potential measured by publications or relative value units, but by how well we love and how we show up for others.
The lessons I have learned from my patients are innumerable, and so yes – we chose a profession where we are surrounded by suffering, and yes, it is difficult and sad and complicated, but it is also beautiful, honorable and saturated with meaning.
My mother and my patients have taught me that the process of dying is not easy. Contemplative medicine has taught me that suffering is inevitable. If I had this understanding of suffering when my mother was sick, I would have been different. I would have spent more time being, sitting with her with openness and curiosity. I would have asked more questions about her life and spent more time embracing and honoring who she was, and less time on a mission to stop or fix her suffering. I would have recognized that the suffering I witnessed was hers to carry, and although I could not bear that load for her, I could be right next to her holding her hand along the way.
Deirdre Pachman, MD is a palliative care specialist at the Mayo Clinic and a 2022 Contemplative Medicine Fellowship graduate. For more information on this fellowship program, visit www.zencare.org.