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Painting and Poetry From a Bereaved Family and the Caring Physician

  • Jamie Xuelian Zhou
    Affiliations
    Division of Supportive and Palliative Care (J.X.Z., C.G., L.K.R.K.), National Cancer Centre Singapore, Singapore

    Duke-NUS Medical School Singapore (J.X.Z., C.G., L.K.R.K.), Singapore
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  • Cynthia Goh
    Affiliations
    Division of Supportive and Palliative Care (J.X.Z., C.G., L.K.R.K.), National Cancer Centre Singapore, Singapore

    Duke-NUS Medical School Singapore (J.X.Z., C.G., L.K.R.K.), Singapore
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  • Min Chiam
    Affiliations
    Division of Cancer Education, National Cancer Centre Singapore (M.C., L.K.R.K.), Singapore
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  • Lalit Kumar Radha Krishna
    Correspondence
    Address correspondence to: Lalit Kumar Radha Krishna, MBChB, FRCP, FAMS, MA, PhD, MD, Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, University of Liverpool, Liverpool, United Kingdom.
    Affiliations
    Division of Supportive and Palliative Care (J.X.Z., C.G., L.K.R.K.), National Cancer Centre Singapore, Singapore

    Duke-NUS Medical School Singapore (J.X.Z., C.G., L.K.R.K.), Singapore

    Division of Cancer Education, National Cancer Centre Singapore (M.C., L.K.R.K.), Singapore

    Palliative Care Institute Liverpool (L.K.R.K.), Academic Palliative & End of Life Care Centre, University of Liverpool, Cancer Research Centre, University of Liverpool, Liverpool, United Kingdom

    Centre of Biomedical Ethics (L.K.R.K.), National University of Singapore, United Kingdom

    PalC (L.K.R.K.), The Palliative Care Centre for Excellence in Research and Education Singapore PalC c/o Dover Park Hospice, Singapore
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Open AccessPublished:March 23, 2022DOI:https://doi.org/10.1016/j.jpainsymman.2022.03.008

      Abstract

      This is a case description and personal account shared by a palliative care physician whose team provided specialist palliative care support to a patient who attempted immolation. This case depicts a family at risk of complicated grief due to the violent nature of self-inflicted burns and the lingering social stigmatization of suicide. Here, we explore important psycho-emotional considerations and share our experience using art and poetry to build therapeutic connections with the grieving family.

      Key Words

      Introduction

      Madam A was a 59-year-old lady who attempted immolation leaving her with 33% of Total Body Surface Area (TBSA) full thickness burns on her anterior torso (13%), upper arms (8%), palms (3%), and anterior thighs (9.5%). Her husband, who saved her, was left traumatized and injured.
      Intubated and supported with inotropes and antibiotics at the Burns Intensive Care Unit (ICU), Madam A succumbed to her injuries days later as a result of her prolonged starvation, sepsis and coagulopathy.

      The Specialist Palliative Care Assessment

      The palliative care assessment was made on the third day of admission for pain control and support of the family. A family conference was held and attended by the Plastic Surgery, Burns ICU and palliative care team, the medical social worker, patient's private psychiatrist and Madam A's husband, son, daughter-in-law and her daughter, who resides in Ireland. There, we learned of Madam A's long struggle with depression and the family's multiple attempts to prevent her suicide. We also realized that this suicide attempt was precipitated by her eldest brother's death a month prior and her inability to visit her mother and siblings in India because of COVID-19 travel restrictions. Psychosocial assessment revealed post-traumatic stress reactions as her husband was experiencing nightmares, frequent flashbacks, difficulty sleeping and irritability whilst her son expressed feelings of guilt for not preventing the suicide attempt. Psycho-emotional support was rendered during the session.
      With her condition worsening, a consensus was reached to withdraw ventilatory and inotropic support so as not to prolong unnecessary suffering. Time was given to the family for goodbyes and rituals before Madam A was extubated. She remained comfortable and died two hours later, in the presence of her family (her daughter via video-call).

      Bereavement Support

      Her daughter reached Singapore a week later but had to serve quarantine. We arranged to have a family meeting to provide bereavement support before the sea burial. During the meeting, three weeks after Madam A's passing, we revisited the narrative of what had happened and discussed with the family how they were faring.
      The family shared the effect of how social stigmatization of suicide affected their bereavement experience; they kept the circumstances of her death private and were unable to grieve openly with others. When we assessed Madam A's husband for post-traumatic stress, we were relieved to hear that initial signs were improving. Her son was also grieving normatively and supported by family. Whilst meditating, her daughter shared a spiritual experience of her mother embracing and kissing her cheeks on the day of terminal extubation. She recalled it to be very real and wished she could re-experience the moment again. As she was a painter, we suggested for her to capture the moment in art.

      Therapeutic Connection through Art and Poetry

      Unlabelled image
      In an email exchange between Madam A's family and the palliative care team, PS shared an elaborate description of the painting. The author JZ chose to use blackout poetry, a form of ‘found’ poetry, using text from PS's description of her artwork. ‘Found’ poetry is poetry created from using existing text.

      The last hug by Jamie Zhou (in the words of PS)

      That morningBefore pulling the plugThe chants of Vishnu SahasranamamBefore saying goodbyeThat momentAn emotional whirlwindAfter the hardest decisionOf my lifeThe cosmosIn absolute chaosThe disbelief and hurtWeighing on my shouldersBut MomHer cosmic strengthHer central energy streamCuts through my turmoilShe is the mountain rangeThat embraces my waistSerene and calmingAs present asThe stars in the skyThat kisses from afarCountless and agelessAs sure as the sunWe live in two worldsConnected in spiritSwaying slowlySide to sideDon't let me goStill crying, still huggingShe spreads out a netAnd we will never part
      The blackout poem consists of four stanzas of eight lines. In the first stanza, the speaker brings us to the moment of the spiritual hug amidst the “emotional whirlwind” and “chants of Vishnu Sahasranamam.” The second stanza describes the tension between cosmic turmoil that threatens her world and her mother's “cosmic strength” that rescues her. The third stanza describes the comfort and permanence of her mother's spiritual hug. The last stanza alludes to how the speaker makes sense of her mother's new existence, now “in two worlds” but “connected in spirit.”
      The clinician's rendering led to a cascade of responses in kind by Madam A's son (AS) and husband (VS).

      After Life by AS

      There is no death, there has never been,there is just life and lifeJust that she now lives hers on one sideWhile we live ours on the otherSure, she is keeping busy with her divine duties,for the hard worker she was and is,a mother never forgets her childrenkeeping an eye on us, not many moments she will miss.Well-wishers and admirers have been plenty,for she lived in her prime with grace,again, there is no death, there is only life,God's plan, I know, will unfold at his decided pace.
      In AS’s poem, what was striking was the fluidity of the tenses – from simple past to present continuous, from simple present to present perfect continuous – which emphasized the theme of continuity in the afterlife. It demonstrated how he had made sense of his new life without his mother; his mother continues to live but in another dimension.

      Untitled by VS

      You accelerated your time lineto the finish line,leaving us unexpectedly,shocking our very being,you have gone too soon.Thank you for all the great memories,being a wonderful wife and mother over the last 37 years.Your love and companionship will be cherished.
      Madam A's husband used poetry to convey two very distinct feelings shock and lasting gratitude towards her. The first stanza contains his disbelief at his wife's act to “accelerate to the finish line”. It hints at a sense of resignation and regret that she had “gone too soon.”
      In the next stanza, he focuses on his immense gratitude and love which cushions the shock of her death. She had nevertheless carried out her roles well in the 37 years of life with them as mother and wife.
      This case depicts a family at risk of complicated grief given the violent nature of a self-inflicted severe burn injury, and whose expression of grief was limited by social stigmatization of suicide. We explore the psycho-emotional considerations in self-inflicted burn injuries, and share our experience using art and poetry in building therapeutic connection with the grieving family.
      Current bereavement theories move away from earlier concepts which describe the grieving process in universally predictable stages. Instead, Stroebe and Schut (1999)’s dual-process model describes the unpredictable oscillation between reconnecting with the deceased and the restorative process of living without the deceased.
      • Stroebe M.
      • Schut H.
      The dual process model of coping with bereavement: rationale and description.
      Neimeyer (2001)’s meaning reconstruction model also acknowledges the bereaved individual's search for new meaning after the loss.
      • Neimeyer R.A.
      Meaning reconstruction & the experience of loss.
      In Weiskittle et al. (2018)’s systematic review, the use of expressive arts was found to facilitate reconnection and meaning-making in the bereaved.
      • Weiskittle R.E.
      • Gramling S.E.
      The therapeutic effectiveness of using visual art modalities with the bereaved: a systematic review.
      Trauma victims often struggle with loss of control and safety.
      Center for Substance Abuse Treatment (US)
      Understanding the Impact of trauma.
      Here, the expressive arts gave the family of Madam A a safe external outlet to experience and process their grief. The spiritual hug that Madam A's daughter yearned for was a need for a continued bond with her mother. Whilst the primary aim of the painting was to memorialize this hug, she made further meaning out of the chaos by reconfiguring and portraying her mother's 'cosmic' existence on canvas as well.
      Hoffman (2014) acknowledged the therapeutic value of using poetry in therapy but also cautioned that ethical issues and risks may arise.
      • Hoffman L.
      The therapists use of poetry in therapy: Deepening relations and understanding through creativity.
      For example, the inappropriate use of poetry may have an unintended negative impact on the therapeutic relationship if the poem is misinterpreted or if the therapist callously imposes on the client unwelcomed thoughts and ideas. The use of blackout poetry here was intended not only to preserve the daughter’s authentic expression of her artwork but also to express empathy and memorialize her description. Blackout poetry prevented the clinician from altering the daughter's intended interpretation of the description.
      The cascade of poetry that followed demonstrated the capacity of the expressive arts to safely contain, memorialize and share overwhelming emotions and grief. It allowed intangible suffering to be made concrete and palpable. It was also clear that bereavement support need not unfold in a physical space – email correspondences could serve as a safe platform for the therapeutic connection and connect family members separated by physical distance.

      Conclusion

      As palliative care continues to trudge into new territories, including burn units, it is important to understand the psycho-emotional impact and suffering experienced by families. In turn, we have to build our repertoire of tools to address suffering. In this case of a patient dying from self-inflicted burns, bereavement care was provided to a family at risk of complicated grief using expressive arts in the form of painting and poetry. The experience led to an unexpected but gratifying exchange: the family was able to process their grief, reconnect with their loved one and make meaning of their new reality without her; the clinician also gained a deeper understanding of their grief and used poetry as a safe vessel to express empathy and build therapeutic connection.

      Ethics Approval and Consent to Participate

      NA.

      Consent for Publication

      NA.

      Availability of Data and Materials

      All data generated or analyzed are included in this published article.

      Conflicts of Interests

      The authors, JXLZ, CG, MC, LKRK have no competing interests.

      Authors’ Contributions

      The authors, JXLZ, CG, MC, LKRK were involved in preparing the original draft of the manuscript as well as reviewing and editing the manuscript. All authors have read and approved the manuscript.

      Disclosures and Acknowledgments

      The authors would like to dedicate this paper to Madam A and her family, VS, PS and AS, who have shared the beautiful artwork and poetry featured in this paper.
      No funding was received for this manuscript.

      References

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        The therapeutic effectiveness of using visual art modalities with the bereaved: a systematic review.
        Psychol Res Behav Manage. 2018; 11: 9-24
        • Center for Substance Abuse Treatment (US)
        Understanding the Impact of trauma.
        Trauma-informed care in behavioral health services. (Treatment improvement protocol (TIP) Series, No. 57.). Substance Abuse and Mental Health Services Administration (US), Rockville2014
        • Hoffman L.
        The therapists use of poetry in therapy: Deepening relations and understanding through creativity.
        in: Heery M. Unearthing the moment: Mindful applications of existential-humanistic and transpersonal psychotherapy. Tonglen Press, Petaluma, CA2014