Lessons in Compassion, from a Palliative Care Pioneer

 

“I am going for a home visit this afternoon,” said Dr M R Rajagopal, to my friend Pallavi and me. “Want to come?”

Of course we did!

The teacher’s presence is enough for a learning to commence, they say. I witnessed this first hand at Pallium India when I had the good fortune to share space with our beloved Dr Rajagopal, Chairman Emeritus of Pallium India, the pioneer of palliative care movement in Kerala.

We sit next to him in the van, as he chats away, asking sundry questions and making us comfortable, and also points out to us the important government buildings and landmarks that we pass by.

That was the first lesson that I learnt: To be humble enough to touch the most common.

 

We drive across a couple of miles and more, before the van comes to a halt outside a lane where road construction is going on. Dr Rajagopal leaves his black shoulder bag behind in the vehicle, but makes sure he carries his smile with him!

I notice the crinkly sand under his black shoes and the calming rhythm that his footsteps make as we make our way towards the patient’s humble dwelling. “This man is suffering from an advanced stage of carcinoma of the rectum” the nurse tells me.

“He and I are from the same village” Dr Rajagopal says, as we walk into his house.

He gently removes his shoes and we follow suit. As with all actions related to him, there is gentleness in this mundane act too.

Here I learn the second lesson: Communication is not only with words.

 

He enters the room, greeting the lady inside, with his characteristic wide toothy smile. She smiles back.

“Who can resist this little packet of kindness?” I reaffirm in my head. He greets the old man lying on the bed and asks him to be helped to get up, saying, “Do you remember me?”

That puts the old man in a warm comfortable zone and he smiles right back at Sir. We must include the language of smiles as the official dialect of palliative care, I quip in my head!

He asks the caregiver a few questions and she says, “He finds it difficult to swallow his food and he has a cough”.  The doctor switches on the torch in his mobile phone and examines the patient’s mouth, discussing with me about the absence of thrush (fungal infection), and only a coated tongue as his sole finding.

I nod in affirmation and say, “Maybe he has lost his appetite and so eats less overall”. I feel included in the story, though I am only an observer.

He places his stethoscope and listens to the lung sounds. He then sits on the patient’s bed, without caring about the not-so-clean sheets over it, goes ahead and performs percussion of the lung fields (a long forgotten technique, given the advent of modern medicine).

He palpates the abdomen and confirms it is soft.

My third lesson – Good clinical skills are imperative and adequate to understand the patient and his disease state.

 

The patient allows to be examined, maybe even liking it, for the fact that someone actually cares enough to travel a long way to take care of an old man.

My fourth lesson – All of us, without exclusion want to be touched and comforted.

 

“He can’t sleep at night” the daughter-in-law says.

My fifth lesson – The caregiver’s history is to be given importance to.

 

“Hmm” Dr Rajagopal makes a mental note. He then asks me, “What do you think we should do? I do not want to prescribe antibiotics for his bad lung. I wish to let him sleep well, that is my priority”.

I agree with him. After all, keeping the patient comfortable was the most important thing in palliative care. “What do you want to prescribe for him?” he asks me.

My sixth lesson – A junior’s opinion is also made to matter, because the gods don’t discriminate.

 

“Tablet alprazolam 0.25 mg; that should suffice” I say.

“Yes. I will go with that. He does not have symptoms of depression or hallucinations for us to prescribe something else”. 

He requests the nurse to give a call to the family the next day to find out how the man slept.

The old man starts crying, holding the doctor’s hands as he readies to leave, and says “I don’t think I have much time left”.

The doctor sits in silence, holding the man’s hand and reaches out to wipe a tear. The man had told him at a previous visit that he knew he was nearing death. He had no unfinished business; felt his life was complete and wanted to go as early as possible.

My seventh lesson – Nobody likes the end, but we can try to make it palatable.

 

Dr Rajagopal then writes out a prescription and hands it over to the daughter-in-law, explaining the medicines to her. He then makes it a point to ask her where she works.

“I am a teacher in a municipal school” she answers with pride.

“Oh, nice!” He beams his smile.

My eighth lesson – Give attention, eye contact and importance to the people in front of you.

 

Again,

She feels valued.

He then goes on to ask her “How is your health? Do you have any problems with your BP or blood sugar?”

“No, I have not checked it, really” she says, definitely feeling cared for, as a real human being and not only the caretaker of the patient. It was not necessary to tell the nurse anything; she proceeded to check the daughter-in-law’s blood pressure and blood sugar anyway.

My ninth lesson – Palliative care takes care of the patient and the caregiver. It gives back the (missing) nobility to the field of medicine.

 

Here, in the 20 minutes of spending time with the patient and his caretaker at home, were learned great lessons in body language, tone of voice, medical knowledge and its appropriate application, all of which Palliative Care stands for.

Compassion and total care no longer needed explanation.

They ceased to be mere semantics.

They had morphed into a man standing in front of me, who exuded calm, kindness and peace and by virtue of being him, passed it on to the patient and his students, a lesson in love was learnt.

Salute to our dear and beloved, Dr Rajagopal.

 

 

About the Author: 

Dr Asha Deshmukh is an Intensivist, with Anesthesiology as her base speciality, working in Nine Pearls Hospital, Nashik.

Dr Asha was introduced to palliative care a year ago, and since then, she has come to believe firmly that community palliative care and integration of palliative care medicine into the critical care units in hospitals, are the need of the hour.

 

Note: The title image features Dr Rajgopal and his team during a home visit. Photo Courtesy: Ms Pratibha