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Humanities: Art, Language, and Spirituality in Health Care| Volume 40, ISSUE 5, P796-800, November 2010

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Poetry and Healing at the End of Life

      Poetry and medicine have common roots in ancient times when the incantation of hopeful spells might have provided the majority of a healer’s interventions. Apollo was the Greek god of both poetry and medicine, with poetry considered the more prestigious.
      Although relative rank may have changed, poetry and medicine still share their dependence on close observation and the careful use of language, asking us to sort reality from illusion. Poetry deals not with general statements but minute particulars, that is, images that can be as revealing as a pathologist’s slide. Yet, poetry also joins the unlikely and carries us along toward wholeness on a raft of metaphors. Metaphors can connect us to the seriously ill.
      • Casarett D.
      • Pickard A.
      • Fishman J.M.
      • et al.
      Can metaphors and analogies improve communication with seriously ill patients?.
      Such connection is a central determinant of healing at the end of life.
      • Mount B.
      Existential suffering and the determinants of healing.
      My first professional training was as a poet although I also completed premedical requirements. I was surprised by admission to three medical schools and asked my poetry mentor Roland Flint for advice. Flint sat me down in his office and told me he did not think I was a genius; unlike Faulkner, for example, he did not think I could go into a basement and come out six months later with a whole fictional county in my head. This was bad news to me, but I listened. Practicing medicine is the best day job a poet could have, he told me, with access to stories not even a genius could possibly make up. Go to medical school and you will be a better poet for it, eventually.
      Arguably, the greatest English poet, John Keats, and the greatest American poet, William Carlos Williams, were both physicians, not to mention the Andalusian Yehuda Halevi, the German Gottfried Benn, and countless others. In German, poets are “die Dichter,” “the condensers,” concentrators of language and metaphor who pack the greatest amount of meaning into the smallest and most beautiful linguistic space. Like ancient incantations, poems are meant to be potent, memorable—memorable in the sense of making a strong impression on memory but also in the sense of being put together in a way that makes them learnable by heart—to be used in performance, revelation, and healing.
      I am not proposing that we return to the time when poetry was commonly memorized for recital. But I have found learning a poem by heart is the best way for me to understand it. Asked what poetry she recommended to hospice clinicians, I overheard a colleague say “anything by Mary Oliver.” When I recite a Mary Oliver poem to a hospice audience, I often see other lips moving in time with my own. A poem known by heart is always available to you, at the bedside, in a classroom, or wherever people might need comfort or illumination.
      A man, not young, my own age, but young to be dying, lingered long past the time the hospice nurses expected and I was asked to make a house call. This is common hospice practice whenever there are concerns with prognosis or a request for a hastened death. When I arrived at the mountainside house filled with light and books, the patient told me that he was unable to give up. He did not want to hurt his family by showing any willingness to leave them. It was difficult to find my own words in the face of our similarities: our ages, professions, the number of our children, and our wives both teachers at the local university. I asked if he could listen to a poem. With his permission, I began reciting Mary Oliver’s “In Blackwater Woods.”
      • Oliver M.
      New and selected poems.
      When I came to the lines “to live in this world,/ you must be able to do three things,” I heard his wife’s voice join me softly, “to love what is mortal;/ to hold it/ against your bones knowing/ your own life depends on it;/ and when the time comes to let it go,/ to let it go.” Only then was this patient able to admit there was a difference between giving up and letting go. He died within a few hours with his family gathered around him.
      Oliver was providing an illustration of the capacity Keats described in a letter to his brothers: “Negative Capability, that is when man is capable of being in uncertainties, Mysteries, doubts, without an irritable reaching after fact and reason.”
      • Keats J.
      Letters.
      In palliative medicine, we learn that not everything can or even should be resolved. As our patients and their families go through this passage together, they may feel both loss and relief; resolution is not required if we have the capacity to embrace both at once.
      Looking back 30 years at the poetry I wrote as an intern, I see a newly forming clinician searching for a way to deal with the unendurable, and in this process, murmuring incantations of agony for his patients. In finding this voice, he also finds his anger, generated by his knowledge that something better is possible; patients’ pain becomes his own and recognition becomes a kind of solace.
      Within palliative medicine, we confess our own needs to be heard and cared for. We all know the flight attendants’ mantra: “Secure your own oxygen mask before attempting to assist others.” This can be self-evidently true without being obvious to an intern, even a family practice intern who chose his specialty in the hope of treating “the whole patient.” It was not until I became a hospice physician that I was asked to show up whole myself, complete with imperfections. Balfour Mount has said that to care for a whole patient, you need a whole clinician. Until that other angel shows up, he admonishes us to “use a team.”
      • Mount B.
      Existential suffering and the determinants of healing.
      There is a lot of talk about teams and teamwork in other areas of health care. Cameron Muir describes end-of-life care as “meaning-making legacy work” (C. Muir, personal communication, 2005). If we do connect in such a way as to do this work well, if we “listen out loud,” as Rita Charon
      • Charon R.
      Narrative medicine: Honoring the stories of illness.
      suggests, to our patients’ stories, then our work must be replete with real loss.
      We can treat pain and shortness of breath, nausea and vomiting, we can change a wet bed, but spiritual suffering does not respond to medications or good nursing care; mainly, we deal with that by accompanying the sufferer. To sustain these connections, endure these losses, and serve our patients as they construct meaning in the face of such suffering, we need nurturing ourselves.
      I have found this in interdisciplinary teams, which are more than just talk, part of the root definition of palliative medicine. Such teams have been places that have encouraged the embrace of uncertainty. What a relief not to pretend to know everything! Often I will sit with a team that shares two centuries of accumulated clinical experience. There is not much such a team cannot do, if you can engage it. Poetry can be one way to accomplish such engagement.
      Interdisciplinary teams have become places to bring poetry, where I have found other writers I could help search for their own voices, while we move together toward the suffering of the dying rather than away from it as our instincts surely dictate.
      Beyond the veil of cognitive dissonance, I think all physicians recognize our medical training in whichever era as having been an ordeal designed to teach enormous amounts of necessary knowledge, which also has had the effect of deadening feeling and increasing our distances from our patients. Whatever solace poetry may have brought me in my first year of residency, by my senior year, I was no longer writing.
      Ever since that training, I have been looking for reconnection like a man with his hair on fire looking for water. It is odd to have found the lake of such connection in caring for the dying.
      I am not a trained practitioner of “narrative medicine,” although I admire Rita Charon’s work and see some reflections in my own. I agree that life is a story, and that we find solace by recognizing and telling our stories—woven into the stories of others. Charon suggests this solace is real; in modern life, we look for meaning most intensely when we are threatened and somehow suffering. In another time, “loss of faith” might have provoked similar soul work in the company of holy ones. Facing mortality now, we often turn to physicians instead of priests. Listening is the central skill for clarifying the goals and values of any life. Charon says “I do not write about many patients in my practice, but I find that writing about some of them intensifies the attention I am able to pay all of them.”
      I have written a lot of orders for morphine, but there is one prescription that is even more common in my practice, for the five tasks of relationship completion: “I love you, I forgive you, please forgive me, thank you, and goodbye.” Following Ira Byock’s lead, I often add a sixth for parents or children, “I am proud of you.”
      • Byock I.
      Four things that matter most.
      After writing these five or six phrases on a prescription pad, I tear the page off and give it to the patient or family member.
      Sometimes there is resistance, especially on the issue of forgiveness. I remember a woman telling me about her husband of 52 years. He never caused her a moment’s worry; even in his illness, he made it clear that she was the most important person in his life. She concluded in tears that she had nothing to forgive him. Silence can be a powerful clinical tool. After hearing her story, I sat still, listening for another moment, and she went on “But the sonuvabitch is dying—Unforgivable.” There can be traction in angry grief, something for the team to work with. Another prescription I often write suggests a visit by the chaplain or the bereavement counselor.
      It is true that undertaking the tasks of relationship completion may be helpful even long after a death, an experience I had when I began writing about my brother, using the same five tasks to structure an elegy 10 years after he died in an industrial accident.
      • Clary P.
      Dying for beginners.
      However, this practice is much more powerful when the loved one is alive and can participate. I think of these tasks as Dutch doors. If you open half, the other half may be opened as well by the one you love, and you can walk through together.
      I had been doing hospice work only a few years when I returned to Montana to help care for my father after his gallbladder cancer moved into its end stages. He was a geneticist, and our relationship had always been difficult, although my brother’s early death had brought us closer. I felt lucky to be able to sit with him at our family home on the Bitterroot River, holding an index card listing the five tasks hidden in my hand as a prescription to myself, and working through them on those cool September mornings. I began by forgiving him for never praising me. He said, “I’ve always believed if you praised anyone too much they’d stop trying.” That seemed then something more to forgive, but it seemed also to be a kind of opening.
      Dad slept through most afternoons, and I spent the warmest part of each Indian summer day on the river itself, reading at the weathered picnic table gradually sinking into a sandbar, or snorkeling for hours just downstream from the sandbar itself among big rainbow trout, a frail human barely able to swim fast enough to stay in one place, watching the fish daintily selecting arthropods and worms washed into their deep pool from the whitewater upstream.
      The Bitterroot, an exclusively catch-and-release river, seemed a melancholy metaphor for my life at that time: in the middle of a divorce, my father dying, mother angry about his sweet openness 50 years too late, my sons on leave from their New England schools to hang out with their wild cousins, driving illegally, shooting handguns at beer cans they had emptied up remote arroyos, smoking illicit Marlboros, and becoming Montanans.
      I got up one morning to find my delirious father wearing only a sagging Depends, chasing my joyfully screaming boys around the house, the old man brandishing a nine iron, and shouting about fire and brimstone. I got the hospice nurse on the phone, asked her to come quickly, and then confronted my father. “Better get some pants on,” I said, “the hospice nurse is coming.”
      He put down the golf club and asked “Which one, the big one or Cathy?”
      “Oh, the big one for sure. You better get dressed, pronto,” I said.
      “Okay,” he said. “I trust you.”
      It couldn’t have been a coincidence that the first praise I ever heard from him arrived shortly after my forgiveness for its lack.
      Cathy was not actually a hospice nurse but a kind of foster daughter who entered our family when I left for Vietnam, and followed my mother into a career in nursing. She drove up from her home in California in a big RV, telling us that she had come to take care of dad and we could not send her home because she had brought it with her. One morning, of course, Cathy, my mother, and my sister Julie all left together to shop in Missoula. I was touched that three nurses would trust me enough to leave me alone with their patient.
      Dad and I talked quietly, with long silences, and the calls of the Canadian geese we could hear far overhead reminded me of a Mary Oliver poem I knew by heart. After I said the poem to him, my father responded, “I like the way you think.” I was touched again by the unexpected praise but protested that the poem was not mine. He told me “You know what I mean, you think the same way,” and fell asleep, allowing no further discussion of Oliver’s assurance that “whoever you are, no matter how lonely,/ the world offers itself to your imagination,/ calls to you like the wild geese, harsh and exciting –/ over and over announcing your place in the family of things.”
      When he woke up, he started to try to get out of his recliner, and I got up from my warm place at the hearth to help him, asking what he wanted. He confirmed my worst fear, heading doggedly and inarticulately for the bathroom with me more-than-half supporting him. He insisted on facing the toilet, to my relief. He managed most of the task himself and began urinating hesitantly, slowly, an almost contemplative look on his face. “It’s funny,” he said, “you never know about anything.” I waited, cautiously watching the dark stream of urine. “Who would have thought that the most important thing I would ever do was have that little bit of germplasm that was going to become half of you come out of me right here?” he said. I helped him wash his hands, speechless, and in doing so washed my own, bathed in a third instance of my father’s praise.
      I had begun hospice work in self-defense in the late 1980s. A public health officer in Brooklyn, paying back a National Health Service Corps scholarship obligation in the early years of the AIDS epidemic, I became hospice dependent, as there was so little else we could do then for so many dying young. By the time I left Brooklyn in 1986 for New Hampshire, I was burnt out—but I had been on fire!
      When I made my first terminal diagnosis in my new practice on the Maine border, the old farmer told me in his Downeast accent that he did not want any part of that chemo. “I’ve had enough doctoring,” he said. He made it sound like a curse.
      I heard him, and I turned to the yellow pages only to find there was no entry for hospice. I called up the only local oncologist at his office. No, he said, there was nothing in the Seacoast region of New Hampshire a city doctor would call a hospice, nothing Medicare certified, but there was a little volunteer-based hospice down the Rollinsford way that did a decent job. I gave the hospice a call, recording a message.
      A few days later, I came in for morning office hours, running late after rounds. My waiting room was full of people in suits. This was not a good sign in a little New England mill town. Drug Enforcement Administration or Medicare? In fact, the suits contained the board of directors of the local hospice on a recruiting visit. They wanted me to join them on the board, as I was the first doctor who had ever made a direct referral to them.
      It was not my last. As the hospice moved toward certification in the waning years of the decade, I began doing house calls to help connect with other physicians, as the nurses taught me another approach to healing, caring beyond cure for the most seriously ill, using metaphors as medicine.
      This approach would bring me back to poetry, which has become part of my work and life, an important clinical tool just as critical for teaching. It is important to note that the practice of expressive writing also has been proven effective in self-care.
      • Stanton A.L.
      • Daroff-Burg S.
      • Swordowski L.A.
      • et al.
      Randomized, controlled trial of written emotional expression and benefit finding in breast cancer patients.
      A colleague, Stephen McPhee, has long used poetry in teaching and clinical work at the University of California, San Francisco. Dr. McPhee’s father told him, “Never leave home without a poem in your pocket,” a practice he has cultivated to the point that he carries a “Poem Pilot,” an electronic device loaded with hundreds of poems,

      McPhee SJ. Beyond advanced directives: Poetry at the bedside. Miller Lecture. Johns Hopkins Bayview Medical Grand Rounds, Baltimore, 2006.

      in contrast to the mere dozen or so I know by heart. I have begun adopting this practice and now find myself with an iPoem in my pocket (www.poetryfoundation.org/iphone offers a proprietary app for this including only poems in the public domain or published in Poetry). Sensitive to the issue of intellectual ownership, I download nothing into this device I also have not purchased in royalty-paying published form.
      I cannot store all the poems I love in my fragile biological memory, but now many more will be available whenever patients, or colleagues, or I myself need them. Having so many more “poems in my pocket” will allow me to expand the practice of bringing the right poem to the bedside or the seminar room to facilitate healing, learning, or both.

      References

        • Casarett D.
        • Pickard A.
        • Fishman J.M.
        • et al.
        Can metaphors and analogies improve communication with seriously ill patients?.
        J Palliat Med. 2010; 13: 255-260
        • Mount B.
        Existential suffering and the determinants of healing.
        Eur J Palliat Care. 2003; 10: 40-42
        • Oliver M.
        New and selected poems.
        Beacon Press, Boston, MA1992
        • Keats J.
        Letters.
        in: Bush D. John Keats: selected poems and letters. Riverside Press, Cambridge, MA1959: 261
        • Charon R.
        Narrative medicine: Honoring the stories of illness.
        Oxford University Press, New York2008
        • Byock I.
        Four things that matter most.
        Free Press, New York2004
        • Clary P.
        Dying for beginners.
        Lost Borders Press, Big Pine, CA2006
        • Stanton A.L.
        • Daroff-Burg S.
        • Swordowski L.A.
        • et al.
        Randomized, controlled trial of written emotional expression and benefit finding in breast cancer patients.
        J Clin Oncol. 2002; 20: 4160-4168
      1. McPhee SJ. Beyond advanced directives: Poetry at the bedside. Miller Lecture. Johns Hopkins Bayview Medical Grand Rounds, Baltimore, 2006.