Personal Views: The good of small things
Authors: Mary J Marret
Journal: BMJ (2003)

I first met “Salmah” when she was about nine. She had cerebral palsy and had spent her life confined to her bed or wheelchair, relying on her family for her every need. To some people it might seem a useless or meaningless existence—always needing someone there to turn, change, or feed her. Yet these were acts of love that her family carried out devotedly. Most of the time she would show no sign that she saw or heard much. Quite often what I elicited were grimaces or protesting moans as I tried to move her stiff limbs while examining her. Once in a while she would surprise us with a broad grin or a near chuckle, as if sharing a good joke.

As time went on I felt increasingly inadequate, with little to offer except regular prescriptions of anticonvulsants or suggestions to improve her seating or her constipation. She grew larger, making it more difficult for her family to move her. Transportation became a complicated logistical exercise.


Everything we do for our patients has a value beyond what we perceive


One of her last admissions to hospital was a prolonged one. What started out as a simple case of pneumonia developed into a severe illness. The subject of possible options in the event of her deterioration was raised. We explored her family's opinions on ventilation and intensive care. I encouraged her parents to discuss the matter with her young adult siblings who were closely involved with her care. Their answers were non-committal, and they left it to me to decide “whatever was best.” It was difficult to gauge whether this was a reflection of their trust or whether they wanted me to ease their burden of responsibility for a decision to let her go. I hoped that I would not have to confront that decision but feared that she would never see her home again.

Then, miraculously, with a few adjustments to her nursing care she managed to recover sufficiently to be sent home. Her parents left with a list of emergency telephone numbers and a promise from me to drop by one day.

I fell prey to the sin of procrastination, as other matters cried for attention—although I kept reminding myself to visit her soon. A month later her parents sent me a message to say that she had passed away the previous day and that they were grateful for our help.

Stricken with guilt that I had not fulfilled my earlier promise, I paid her family a visit later that day. She had been buried the previous day, according to custom. Her family was in the midst of preparations for memorial prayers that evening when I dropped in. Her parents were surprised at my visit yet greeted me warmly and apologised for the bare living room, from which all the furniture had been cleared.

We sat down together on the floor, and they pressed me to have some tea as we spoke of many things. They related the events leading to her death. She had been relatively well and happy after her return home. They had celebrated her birthday only the week before. Then she had developed a slight fever. It seemed like a mild illness and did not cause any alarm, but she had passed away in her sleep that night. She had died in the arms of her sister, who usually slept with her.

They told me about her funeral and how relieved they were that everything had gone smoothly and that the proper rites had been observed. We exchanged knowledge about various customs of our respective cultures in relation to death and mourning. Salmah's family belonged to the local Malay Muslim community, while my roots were Indian and Christian, yet our different worlds had some basic similarities.

Her family showed me pictures of Salmah from the family album. There were photographs of her as a baby and at different stages of growing up. It was an enlightening experience to look at her through a different prism—not as a patient whom we might classify as “completely dependent” but as a beloved member of her family, in everyday situations and pretty clothes, and included in family events and celebrations. They proudly introduced me as “Salmah's doctor” to members of her extended family.

I had ventured on this visit with some trepidation, uncertain of the reception I would get. The warm hospitality and the opportunity to speak with her family opened my eyes to things I would never have known otherwise. Had I not made that trip I would not have appreciated how much she meant to her family. I learnt that many little actions over the years, which I may have considered insignificant or even pointless, had a great impact on easing the situation for Salmah and her family. They knew and accepted that this end was inevitable. What mattered to them was that she had managed to return home and had departed peacefully in familiar surroundings with her loved ones close by. This was much needed reassurance for me that everything we do for our patients has a value beyond what we perceive. To Salmah, who taught me these important lessons, may your soul rest in peace.