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Mindful Practice

The gift of letting go

Casey, Shannon PA-C

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doi: 10.1097/01.JAA.0000586380.65361.63
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When I was a PA student, I chose neurology as my elective clinical rotation. The brain fascinated me, especially the ways that damage to different parts of the brain manifests. When I was a teenager, my dad had a brain tumor, and he would occasionally blurt out phrases like “reindeer and rainbows!” and “the fishermen feed the fish!” seemingly at random. I learned that this is called “salad speech.” It was an intriguing phenomenon.

During my neurology rotation, I accompanied the attending and her PA on rounds, whenever a patient needed a lumbar puncture, and any time there was a stroke alert. These experiences were all informative, but one interaction in particular has stuck with me even years later. One afternoon, I stood by the attending's side as she evaluated a comatose young man. The corneal reflex was absent. He had a Glasgow Coma Scale score of 3.

Four of the young man's family members filled the small room. “Could he still wake up?” someone asked through tears. Everything hung on that one question, and the neurologist's answer. “I've never seen anyone wake up from this,” she replied, gently but clearly. She gave the family a moment to take this in.

Afterward, when I talked with the neurologist about the encounter, she confirmed that the phrasing of her response had been deliberate. To avoid broaching the subject of the notoriously controversial stories about patients waking up from comatose states, she didn't say that it wasn't possible for the young man to wake up.

“Sometimes, you have to give the family permission to let go,” she told me. As the neurologist, she had the ability to take away the burden of ambiguity and, to the extent that was possible, that's what she did. She removed the weight of hope and replaced it with the gift of letting go. “This is the only way that they will be able to make peace one day,” she added.

At the time, I felt conflicted about this. On one hand, her response to the family's question could be construed as deceptive, even manipulative. On the other hand, her explanation made sense. I knew that her words and actions were informed not only by clinical competence but also by the hard-earned wisdom that comes from years of experience.

Gradually, I've realized that what the neurologist demonstrated that day was the art of medicine. We have the privilege of being with patients and their families on what may be the worst day of their lives. We have the responsibility to make that day a little bit more bearable. Drawing on the virtues of compassion and mercy, the neurologist gave that young man's family the gift of letting go.

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