THE MANY TIMES I practiced chest compressions and mouth-to-mouth resuscitation on CPR mannequins for basic life support (BLS) recertification, I never imagined the surreal experience of performing CPR on my own mother, in her bedroom, in front of other close family members. I have never served in combat, but I can now imagine the flashbacks experienced by those who have witnessed the horrors of war. Memories of that day in my parent's home sometimes jolt me like an electric shock during conversations about goals of care with my patients and their families on the palliative consult service. One such conversation remains fresh in my mind from just a few weeks ago.
UNCOMFORTABLE SILENCE AND VEXING QUESTIONS
The patient was a man in his 50s with relapsed, refractory leukemia whom the oncologists were trying to guide toward a comfort care route since he had exhausted all treatment options for his leukemia. The treating team asked us to assist with this transition and to manage symptoms. The patient and his family were all from the Indian state Punjab, which borders Pakistan, my parent's home country, so I am fluent in their native language, Punjabi. The patient was delirious and therefore unable to communicate more than very rudimentary information, and his wife spoke only Punjabi. As a result, the patient's wife deferred all substantive communication to their young adult son, who was fluent in Punjabi and English, having studied and worked in the United States for several years. They had a daughter as well but she lives in India with other family members. The situation placed a tremendous burden on their son, who was to participate in all communication with the healthcare team and make many important decisions on behalf of his father.
Before I entered the room for the first time, I debriefed with the bedside nurses, who explained that the family was very emotional and overwhelmed. The son was seemingly upset with the quality of his father's care, but he was in fact grieving his father's impending death and was having difficulty expressing his grief. As a result, he often came off as passive and was sometimes even a bit surly. I thought this young man might be having difficulty communicating with female staff, so I hoped to be able to connect with him better. After introducing myself in Punjabi and explaining my role, I asked how we could help the patient feel better, looking back and forth between the patient, his wife, and their son. The patient was deeply delirious and minimally responsive, and his wife was silent despite the fact that I addressed her in her native tongue, so I turned my gaze to his son. He was silent for several seconds and then responded in English “Why is my dad not eating? What can you do about it?” I replied, “I know how badly you want to ...