Pieces of Grief

DOI: 10.1200/JCO.2015.62.1334 I struggle to remember Taylor’s face as he died. I piece together kaleidoscope fragments, but they blur in and out of focus: his sunken eyes, the sharp angle of his jaw, his cold fingers, the sucking spaces between his ribs. I’ve grown used to how the broken shards of people become embedded in my subconscious. I am careful—paranoid, even—about handling each memory fragment gingerly, lest it slice into a place within myself where it might linger like a splinter. The end of Taylor’s life intersected with the end of my first year of pediatric hematology-oncology fellowship. Taylor was 15 years old, he had lymphoma, and he was dying. Many of my patients could be reduced to similar sound bites: age, disease, and acuity captured in quick one-liners. Initially, I rebelled against these synopses, injecting flowery language into my verbal and written reports in an effort to capture the spirit of my patients beyond their illnesses. I grew particularly fond of using adjectives like “feisty” or “precocious” to describe my patients, and I gladly accepted the inevitable teasing of my colleagues in return. Yet as I cared for increasing numbers of patients, I found it difficult to genuinely know children and families in a meaningful way that transcended their diseases and treatments. In the late evenings, I would try to circle back to the bedside in search of a few nonmedical moments. I remember these visits vividly: we sang, played board games, talked about life beyond the hospital. Often, I did not begin writing notes until after midnight. It did not take long before this pattern became unsustainable, and I started to unravel. Exhausted and anxious to prove my competence, I learned to prioritize proficiency and productivity. There were too many patients and too few hours in the day, with each shift morphing into a zero-sum game governed by meticulous triage calculations. To maximize efficiency, I mastered the art of collapsing patients into their disparate parts: vital signs, pain scores, input/output, laboratory values, medication doses, imaging studies. Over time, I started to believe that the key to healing my patients lay in these details, if only I were smarter or faster in gathering and deciphering the essential pieces. In the midst of this incessant data collection, I also was a front-seat witness to horror and heartbreak on a daily basis. Each layer of tragedy felt more raw and unbearable than the last, and I struggled to empathize deeply without falling apart. Coping might be easier, I thought, if I could figure out how to strip suffering down to objective, depersonalized data, and then methodically process it. To achieve this goal, I deliberately tried to observe grief from a bird’s-eye view, using distance as a protective shield against the anguish of individual faces and stories. I knew that sadness was intrinsic to my chosen career, and I began to wonder if detachment might be a partial antidote to—or better yet, a preemptive strike against— grief. The culture of oncology has a long history of stigmatizing death and the dying process as well as condemning emotion as weakness. Sensitive to this stigma and eager to fit in, I became preoccupied with learning how to turn my emotions on and off, akin to flipping a light switch. Yet as I ran from one terrible death to another, I struggled to slip into autopilot. Ironically, the more I strove for emotional self-regulation, the more emotionally unbalanced I became. On a subliminal level, I think I was afraid that, should I succeed in turning off my emotions, I might forget how to turn them back on. Or, perhaps worse, I might not want to. Secretly, I envied my colleagues who seemed able to move gracefully between devastating events, their objectivity and empathy unclouded by the surrounding emotional turmoil. I, on the other hand, absorbed the emotions of my patients and their families with an intensity that both blinded and consumed me. In public, I strove tomaintaina facadeofcomposure,busying myself by accounting for every medical detail. Yet privately, I wept in my car on the drive to and from the hospital. In the rare hours that I slept, my nightmares were filled with montages of vital signs and laboratory values splayed across disembodied organs, all of the images nameless and faceless. In retrospect, in my drive to compute medical minutiae, I gradually lost count of what mattered. Faced with relentlessly high patient numbers and acuity, just completing the requisite daily tasks was often unfeasible; finding time or a quiet place to reflect on the life and death of each child simply did JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 33 NUMBER 26 SEPTEMBER 1