Hospital Allegory: (Special thanks to Keiki Hinami).
Three scientists are tromping through the wilds of a previously uncharted rain forest. They are captured by blood thirsty aborigines who scream and chant at them. The Chief approaches the first scientist as asks him, “Do you want death or do you want cheech?” The natives whoop and holler. The scientist, shaking in fear, has no idea what cheech is, but does not want to die, so fearfully chooses “cheech”. The aborigines yell and scream, yank out the scientist’s eyeballs, slice open his abdomen, pull out his entrails until he crawls off moaning in agony into the jungle to die. The second scientist is then approached. “Do you want death or do you want cheech?!” The second scientist is in a state, saying convulsively over and over, “I don’t want death; I don’t want cheech!” The Chief demands an answer and the scientist, with panic and reluctance, chooses cheech. The natives whoop and scream, slice the scientist open, and torture and render him with a hot poker, until the scientist crawls off moaning in agony into the jungle to die. Now it is the third scientist’s turn, and he is ready. The Chief approaches him and asks him his choice, death or cheech. “Death,” the third scientist confidently states. The crowd goes silent and the Chief nods approvingly. “Death!” he says. There is a pause. Then the chief says, “But first, a little cheech!” And the crowd goes nuts.
This is medicine. This is in fact, hospital medicine. First of all patients have no idea what “cheech” is. They don’t truly understand the miseries, both petty and major, of the choices they are making. Those of you who have ever had an NGT for any duration will understand the point. They don’t know how to evaluate the level of “cheech” in going home on chronic TPN, or with a decompressive g-tube, or with a million other choices they are given. They just know they don’t want death. And even when they have the stalwart discipline to choose the often blessed relief of death, what do we do? We say ok, but before you go home to die, lets put in a peritoneal drain to make you comfortable, or let’s complete your course of IV antibiotics or let’s dialyze you for a couple of days. And on and on.
And as aborigines, we lack the same empathy and understanding of “cheech”. In some ways we are just dancing around, doing what we naturally do. We order things, plan interventions, hang out with other natives. But do we really stop to understand the petty miseries that plague our patients, the “cheech” that makes death a silent and welcome relief sometime? No, we just order more cheech.
This fable, given to me by the previously noted Keiki Hinami, and surely given to him by a wise elder who understood things in a bigger picture way, should really infuse what we do. First we need to evaluate our interventions for misery. As aborigines, er providers, we need to truly understand in a corporeal way, that the things we do to people hurt, cause indignity and often suffering. We need to let people choose death, not only as a way to avoid this cheech, but also just allow patients to choose a cheech-less existence, with death being or not being the consequence of such a choice.
So learn from this. I did.
Tracy Cardin, ACNP-BC, SFHM is the Associate Director of Clinical Integration at Adfinitas Health and also serves on SHM’s Board of Directors. Prior to this, she was the Director of NP/PA Services for the University of Chicago and worked in private practice for a group of excellent pulmonologists/intensivists for over a decade. She has been a member of SHM for over ten years and has over twenty years of inpatient experience, which seems incredible as she cannot possibly be that old! Her interests include integration of NP/PA providers into hospital medicine groups and communication in difficult situations.
In her free time, she likes to run and lift, read and write and hang out on the front porch of her semi-restored Victorian house with her dear family and friends while drinking a fine glass of red wine and listening to whatever music suits her whimsy.