Innovations in End-of-Life Care
an international journal of leaders in end-of-life care

Mary Kraft, MD, MPA

[Citation: Kraft, M. Being and Doing: Adding a Spiritual Dimension to the Practice of Anesthesiology. Innovations in End-of-Life Care, 1999;1(6), www.edc.org/lastacts]

My sport is horseback riding. If you ride long enough, sooner or later, one moment you're on the horse and the next you're on the ground, looking at the sky, slightly dazed and breathless.

I remember feeling just this way—slightly dazed and breathless, with a touch of nausea—on a March day in 1994, when Hannah, my husband's 21-year-old granddaughter, called to tell me that the strange brown lump on her right thumb was a malignant melanoma. As an anesthesiologist, I only see such patients early on, when the manifestations of whatever disease are surgically removed. My visceral memory was of a time in medical school, some twenty years earlier, when a fellow student's wife died of this disease.

We were very close to Hannah and her family. While the mother/grandmother in me prepared for the clan to take up residence in our home, the doctor in me searched the Internet and found that, in some cases, the prognosis in 1994 was as devastating as the prognosis in 1974, staved off by a few years.

Fast forward to 1997. Hannah had metastases. The brain mets would be treated by radiation. The abdominal mets could not be treated at all. What could I do? Doctors are trained to do. The anxiety and awfulness of the whole situation was made so much worse by not being able to do that which I (and her "real" doctors) had been trained, acculturated, and accustomed to do. Her "real" doctors signed her off to the palliative care specialists. I faced despair.

Wait—perhaps it was time to return to something else I knew how to do (aside from making chicken soup). I knew how to pray. But pray for what?

Miracles? I don't exactly believe in miracle cures. They're OK from a distance, but when you have a former athlete in your living room who can barely sit up, whose belly is swollen with ascites, and who is hairless from radiation, the cognitive dissonance is too much.

Then the words of the Jewish prayer for healing came to me:

May the source of strength
who blessed the ones before us
help us find the courage
to make our lives a blessing,
and let us say, Amen.

Bless those in need of healing
with refuah shleima,
the renewal of body,
the renewal of spirit,
and let us say, Amen.

The first stanza places the emphasis on the individual, praying, "Help us find the courage." So, I prayed for myself to be a source of courage—to just be with Hannah during her last days, which were spent under our roof.

As I became more aware of the need to let go of the doing part of me and become more attuned to the being part of me, I sensed in my patients the desire to have a caregiver stop and be for a moment. From my own experience, I called this desire for a moment of connectedness "spirituality."

While all of this was happening at home I read about the Schwartz Fellowship in Clinical Pastoral Education (CPE). I jumped at this opportunity, for by that time I had figured out that I had the desire to connect in this way with my patients—and perhaps even had some innate ability—but I lacked the vocabulary and any formal training. Furthermore, I wanted some supervision of my attempts to engage patients spiritually.

The application process (completed after Hannah's death in July 1997) was educational in itself. Sitting down and committing to paper my spiritual journey and the turning points in my life was far from the multiple choice, "just the facts, ma'am" process to which I had become accustomed. After the prideful flush of being selected as a Schwartz Fellow passed, I was faced with the reality of turning in an exercise every week, in which I recorded verbatim the conversation I had had with one of my patients in a clinical setting. I learned to ask patients about faith and prayer and their notions of the Spirit. I learned to ask them what gave them meaning in their lives and what their real concerns were in facing their illnesses. The more I engaged in these conversations the more natural it became, and there were some incredibly "high" moments of bonding and connection that I had never felt before.

Take for example, Mrs. Farmer,¹ a 56-year-old dairy farmer from Nigeria, who had previously taught school for many years. She had undergone two craniotomies in the space of a week for arteriovenous malformations and was now my patient in the radiology suite for angiography and embolization of her remaining feeder vessels. She had had several arterial lines for her prior surgeries, and accessing a radial artery again was a challenge. After several attempts, I succeeded. She said, "Ow, that hurt!" I told her that I regretted causing her pain, and acknowledged that she had been through a lot. I then asked her how she coped with all that had happened to her recently. She told me that she prayed. I asked her if she would like me to pray with her right then and there. She said, "Yes." We agreed on the Lord's Prayer. With my right hand, I held in the hard-won arterial line, awaiting some tape. With my left hand, I held her right hand, and we said the Lord's Prayer together, oblivious to the hubbub going on around us. When she stopped at "Deliver us from evil," I said, "Oh, you're Catholic." She said, "Yes." We had a giggle, she felt better, I felt better, and all the people in the room were amazed.

Mindy was a young woman in her late thirties, who visited our Pre-Admission clinic before a lumpectomy. She had a young daughter, and her husband had recently walked out on the family. I asked her about her support network, and she told me of her family, friends, and therapist. I then asked her if spirituality or faith played any part in her life, and it was as if I had opened the door to a huge aspect of her life that she never expected anyone at the Massachusetts General Hospital (MGH) to acknowledge, much less reinforce. She later remarked that MGH was the last place she expected to find God. Nevertheless, there we were, talking about the importance of faith in her life. I told her that she could bring her pastor with her to treatment, and that was a tremendous source of comfort for her. A year later I had the opportunity to hear her speak from the pulpit of her church. Here was a woman for whom faith was an anchor during a lot of stormy weather, and I never would have known that, had I not bothered to ask the question.

What about those patients for whom faith plays no part? How could I reach them with a moment of connection? I have been on occasional "fishing" expeditions. Mrs. Ferris, a 62-year-old woman, came into my office before a knee arthroscopy, so anxious she could barely sit still. After several unsuccessful forays into her world, I asked in desperation, "Isn't there anything you enjoy doing that takes your mind away from your troubles?" She emphatically responded, "Yes—ironing! Would you like me to iron your shirts?" I politely declined her offer, but suggested that, while she was awaiting her surgery, she remember what it felt like to be standing at her ironing board. Her expression changed to one of huge relief, and she was very thankful for my time and interest. I felt good about the interchange as well.

Almost two years have passed since I started my CPE training. I have gained an enormous amount from this experience, both personally and professionally. I have learned to be still within myself and balance doing with being in everyday life. When things get overwhelming, I try to just breathe. Life is breath. In a few moments, I can get back on the horse, center myself, and begin again. The more I am able to do this for myself, the more I can remain grounded, focused and present with my patients. Unlike a rote medical history, this focus on presence helps make a connection with the patient and can turn the most disquieting moment into a space of calm.

Not long ago, I was anesthetizing Dr. Barrie, a 42-year-old female chemist, for excision of a brain lesion thought to be the cause of her seizures. "Anxious" does not do justice to this patient's emotional state, and her anxiety was beginning to be contagious. She denied interest in prayer, meditation, or relaxation techniques. I asked her if she could visualize, just for a moment, a place where she felt calm and relaxed. After only several minutes, she began telling me about her A-frame house in Vermont, with the trees and the loons on the lake. She became more peaceful, those around her became more peaceful, and she fell off to sleep with a calm expression. I consider that experience a "win." In this calm place of connection the Spirit is free to enter, and the enhanced job satisfaction I feel is immeasurable.

1. I have changed the names to protect the privacy of the patients involved.