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Finding the place where both truth and hope reside

Zarbock, Sarah PA-C

Journal of the American Academy of Physician Assistants: April 2009 - Volume 22 - Issue 4 - p 10

In Greek mythology, Pandora was the first woman on earth. The gods endowed her with many talents—hence her name, Pandora, meaning “all-gifted.” She received a box from Zeus that she was forbidden to open under any circumstance. Impelled by her natural curiosity, Pandora opened the box, releasing all the curses into the world. All blessings escaped as well and were lost, except for one thing that lay at the bottom, and that was hope, without which mortals could not endure. Jerome Groopman, noted physician author, in his book The Anatomy of Hope explores hope through intimate portraits of patients at pivotal moments when they find hope or it eludes their grasp. He also tries to answer the question of whether there is a scientific basis for understanding the role that hope plays in illness and its outcome. Especially intriguing is his exploration of whether there is a middle ground where both truth and hope reside.

As health care providers, PAs have developed an approach to medical care that permits them to recognize the clinical manifestations of disease, apply physical examination and test findings to support a diagnosis, recommend particular treatments, and monitor outcomes. At each point along the way, we also have an opportunity—one that we often miss—to recognize and respond to our patient's perceptions, reactions, and concerns and to adjust our care to more closely meet the many facets of their needs. This task is more urgent when the patient is chronically, seriously, or terminally ill because often these cases are in a race against time. How do we as clinicians balance telling the truth with maintaining hope?

To better understand our professional experience of caring for our seriously ill patients, JAAPA is sponsoring “Caring for Patients with Life-Threatening Illnesses,” the second in a series of sessions in the medical humanities. The format of these medical humanities sessions includes discussion of a creative work that allows participants to gain insight into patients' experiences of their medical care. This year, we will focus on the 2001 film, Wit, starring Emma Thompson and Christopher Lloyd, based on the Pulitzer prize-winning play by Margaret Edson. The story is told around a central character, Vivian Bearing, who, at the age of 48 years, develops aggressive ovarian cancer. Her medical providers convince her to undergo high-dose chemotherapy, and in the course of her treatment, she begins to examine and reflect on her life as she becomes less of an individual and more of a “case.” Sadly, one of the more dismal aspects of her care is the lack of her caregiver's appreciation for and integration of hope— both in providing it to her and in exploring its role in her life-threatening illness.

In 2002, supported by the Robert Wood Johnson Foundation, the Wit Film Project was developed; this innovative medical training program used the Emmy Award-winning HBO film adaptation of Wit to advance education on end-oflife care.1 Watching and discussing Wit provides an important opportunity for PAs to examine the content and style of their interactions with patients, as well as to see how both providing hope and eliciting hope can guide decision-making for seriously ill patients.*

The Wit Project curriculum addresses quality of care for the dying and some of the issues dealt with in the movie. It also describes the steps a clinician can take when having these difficult but crucial discussions. First, prepare for the discussion by identifying and convening key participants. Determine and clarify what the patient and the family know and what they want to know about the patient's condition. Take the conversation to the next level by exploring their expectations, hopes, and fears. Suggest realistic goals by providing guidance on the basis of medical data and clinical expertise. Finally, work collaboratively to make a specific plan. Preparation is key to this process.

While communication skills and professionalism can be taught in a “how-to” lecture format, hands-on learning can certainly facilitate this process. We encourage you to watch the movie Wit before the annual conference in San Diego and to begin formulating your ideas about your own feelings when it comes to having discussions with patients with lifethreatening illnesses. Most of us feel uncomfortable at one time or another. What can I say? How can I be better at this? Our conference presentation will provide specific tips and consider wording that can be used for these conversations. It will also consider how the provider-patient relationship is the journey we take with our patients in helping them know the truth of their experience but also exploring the importance of hope that can bring special meaning to our lives. JAAPA

* *Our hope is that participants will already have seen Wit in its entirety before attending this session; but we plan to show short clips from the film during the session, so please don't be dissuaded from attending if you haven't seen the film.
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1. “Wit” Film Project. Innovative medical education for end-of-life care. Available at http://www.growthhouse.org/witfilmproject. Accessed March 3, 2009.
© 2009 American Academy of Physician Assistants.