dyads in palliative care: the art and science of what we do

Dyads in Palliative Care:

Balancing the Art & Science of what we do

Dyads in Palliative Care:

Balancing the Art & Science of what we do

Suzana Makowski, MD MMM FACPDirector of Palliative Care

Service & Education – Cancer CenterUniversity of Massachusetts

School of Medicine

Suzana Makowski, MD MMM FACPDirector of Palliative Care

Service & Education – Cancer CenterUniversity of Massachusetts

School of Medicine

Basho

We shouldn’t abuse God’s creatures. You

must reverse your haiku, not:

A dragonflyremove its wings -

pepper tree,

BUT

A pepper treeadd wings to it -

dragonfly.

DyadsDyads

Life

DEATH

HopeDespairCuring

healing

Art

Science

Morning Report: The training ground

1st: How to elicit complaints/symptoms/concerns2nd: How to create a differential diagnosis3rd: How to test/evaluate to narrow down the diagnosis4th: How to treat the disease…

But…

What is next? What happens when this problem can’t be

fixed?Science, knowledge is missing…

Bill SarnoffBoard member

Bravewell Collaborative

Bill SarnoffBoard member

Bravewell Collaborative

“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...”

“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...”

Dr. Robert Martensen

• “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.

• 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.”

Mr. & Mrs. Adams

Asphodel, That greeny flowerby William Carlos Williams

Asphodel, That greeny flowerby William Carlos Williams

It is difficultTo get the news from poems

Yet men die miserably everydayFor lack

Of what is found there

Negative Capacity – Dyads - Dissonance

Keats:The ability to hold and cherish opposites in one’s mind at the same time.The ability to live in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason.

Coulihan: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.

DissonanceLet me explain dissonance. Dissonance can be described

as notes whose frequencies are less than "harmonious” to our ears.

However, dissonance is a requisite part of most music that we hear, providing it with "tension" that leads to "release. "Without it, we end up with music that tends to command little attention.”

- Mark Hanson

Michael Kerney: “Being connected... A key to my Survival”

JAMA - March 2009

• Exquisite empathy

• Self-awareness practices Mindfulness Reflective writing Humanities (music)

• Momentary Surprises

(video clip 4)

Windows of the Heart: Science as Art

Otago Daily Times

Windows of the Heart: Science as Art

Otago Daily Times

Dame Cicely Saunders

Dame Cicely Saunders

“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.”

“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.”

So we are called to dive into the Dissonance of the dyad,

The irritable uncertaintiesOf life – deathScience – art

Patient – clinicianI – Thou

But into the dyad we bring to it a thirdWe call that Colleague

SpiritPresence

Love

Wisdom of community

Giving permission

On Breaking Bad Newsafter William Carlos Williams

By Emily FerraraNourish the subtle body between

“I” doctor, and “Thou” patient.

Tend not to the news—for lackof what is found there (men die

every day)—but to what is found between. The unarticulated

fear, sadness palpable in the deepening dark, broken by touch, eyes brimming

hollyhocks, double-blossomed whiteand multiple magentas take breath

give life, subtle body, what is foundis nourished, is all we have. Lean in.

Video clip 1