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Introduction

I still have nightmares.

 —CARDIAC SURGEON REFLECTING ON BEING AN INTERN DECADES EARLIER AND TELLING A FAMILY THEIR LOVED ONE HAD DIED

 

I (Vicente J. Velez) stood outside the door of a family meeting room, hesitating to knock. Inside waited the wife and the mother of John, a patient who was admitted yet again to the hospital for pneumonia and respiratory distress. For years, John had suffered a rare and cruel neurodegenerative disorder that slowly but surely robbed him of his youth, vitality, and spirit. He was known and loved by many. He was a husband, a father, a son, and a friend. I stood there like I had many times before. This time, though, something about the scenario hit too close to home. I stood frozen, paralyzed by fear and sorrow; it was my job to deliver the news that John might have only a few months left to live. It would be necessary to facilitate a discussion about planning the last days of his life. The medical team knew that this was not a discussion that the family was ready to have. During past encounters, they had refused to believe he would die from this disorder.

Empathy is a hardwired trait. When other individuals suffer, we can imagine what it might be like to be in that person's shoes and our brains actually register the feeling. This capacity likely facilitated the growth of civil, structured societies based on justice, the common good, and shared goals. In some sense, we evolved to have the pain of an individual become the pain of the tribe. Medical training could not completely numb a very real neural mechanism that took millions of years to develop.1 In the case of John, I saw myself in him. Death can come to anyone at a moment's notice. There was an undeniable possibility that one day I could very well leave my wife a widow at a young age, have my parents endure the agony of burying their child, and never give my young child the opportunity to play a game of catch with Dad.

On that winter afternoon many years ago, I had to deliver news that would bring pain I would not wish on anyone. As I was in the midst of fulfilling this unwelcome responsibility, John's family members, in deep pain that turned into rage, blamed me—for not having a cure, for not trying hard enough, for abandoning them at their darkest hour, and for his impending death. It was an afternoon that stays with me to this day.

Medical practice is a minefield of encounters that haunt clinicians.2

Doctors in popular culture have consistently been portrayed as poised, objective, and heroic,3 yet the reality is that they, too, suffer as a result of the care they provide....

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