Palliative Care: “Parting is Such Sweet Sorrow”

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Original story posted on: May 16, 2018

The author describes his imaginary interview with William Shakespeare on palliative care.

Before he died just a bit over 400 years ago, William Shakespeare had written almost 120,000 lines and about 900,000 words. His 37 plays and 154 sonnets led to his reputation as the unrivaled wordsmith of the English language. So I have wondered what the Bard, who seemed to have had something to say about everything, would have said if he was asked about palliative care of the suffering sick. So while I couldn’t resurrect him from his venerated grave to get answers, I did unearth quotes from his collective works which spoke to the question of human suffering. My interview with William Shakespeare, I imagined, would go like this:

Mr. Shakespeare thank you for agreeing to chat with me. I have read that in Queen Elizabeth’s England unrelieved pain was pandemic in the Old World and that unrelieved physical anguish was equally rampant in the New World, too. Caring for the physical, psychological, and spiritual pain caused by disease is a challenge that is not being met everywhere even today. Can you tell me why you wrote so poignantly about harsh human suffering?

O, I have suffered with those I saw suffer! A brave vessel who had no doubt some noble creature in her –dashed all to pieces! O, the cry did knock against my very heart! Poor souls, they perished!

The Tempest

Well, more than four centuries after you wrote these words the sick are today still being “dashed all to pieces” but their being dashed to pieces is still underappreciated. But those whose death is closing in on them and their loved ones desperately need to be told the truth about their prognosis. Because a prognosis provides predictive information which is needed to develop a coping strategy for their suffering. But in your opinion, can’t the sick just keep a stiff upper English lip as they come to the end of their life? Do you really think being prepared by their physicians for death is all that important?

Tis a vile thing to die, my gracious lord,
When men are unprepared and look not for it.

Richard III

Vile? Well, Mr. Shakespeare, I can see why you are the inestimable wordsmith! Vile is a tiny word that expresses something that is extremely unpleasant which the lack of substantive palliative care truly is. In 20th century parlance we tend to say ‘regrettable’ when we mean vile in discussing the present paucity of palliation. Perhaps, if we used your 16th century expressions we might make more progress in overcoming the lack of palliative care. Incredibly, today many, many physicians continue to treat a patient for cure when there is no hope of the disease being overtaken. What would you say about a doctor who only fights death and but not the suffering that attends dying?

There is no more mercy in him than there is milk in a male tiger.

Coriolanus

Wow! A ‘male tiger’, ‘no mercy’ – you really are a poet! And you certainly are passionate about palliative care. I am being to get your drift. So I take it that you are implying that those unfortunate patients who have been mastered by their disease and their families can have their sufferings significantly ameliorated by being told the fateful truth about their fate. So, are saying that those in anguish can have their hearts heartened even when facing brutal truths by being surrounded by truly caring souls who will help comfort them? Do I have that right?

Who alone suffers suffers most i' th' mind,
Leaving free things and happy shows behind;
But then the mind much sufferance doth o'erskip
When grief hath mates, and bearing fellowship.


King Lear

I have imagined that you have actually visited with or personally knew patients who were in physically painful and emotionally doleful conditions as death encroached more and more into their lives. How have they described the lack of palliation for their sufferings?

For now they kill me with a living death.

 

Richard III

Living death? That’s sounds very much like something you would write in one of your plays, however, we are not talking about fictional plays but real patient’s lives. It seems for many doctors all their care is focused on just preventing death. But many patients do not want to fight dying to the very end with all the therapeutic might that medicine can muster. They want to be comforted when they cannot be cured. What have those poor souls overcome by their disease without hope of recovery told you about having curative treatments being inflicted on them all the way to the very edge of their death?

Tired with all these, for restful death I cry.

 

Sonnet 66

Yes, I can understand that. Death is respite from unnecessary suffering when all that continued medical treatment leads to is even more unnecessary suffering. It does seem all rather really meaningless if patients are being kept alive but don’t actually have a life any longer – they just exist to be sick. I have read the questioning words you put in Hamlet’s mouth about 'Whether tis nobler in the mind to suffer the slings and arrows of outrageous fortune, Or to take arms against a sea of troubles, And by opposing end them'. Are you saying mercy is necessary to aid those unfortunate patients with outrageous suffering from their unfettered diseases? You did mention mercy earlier, why is mercy so vitally critical in caring for those adrift in a sea of suffering?

Sweet mercy is nobility's true badge.

 

Titus Andronicus

Mercy? Wasn’t that one seven cardinal virtues back in your day? I see your point about the need for more mercy in the care of our sisters and brothers who walking an agonizing path leading to the end of their lives. Do you have any closing thoughts about why mercy benefits the patient and doctor alike?

The quality of mercy is not strained;
It droppeth as the gentle rain from heaven
Upon the place beneath. It is twice blest;
It blesseth him that gives and him that takes.


The Merchant of Venice

Yes, more mercy would be a blessing to us all. It is a painful tragedy that these blessings cannot be experienced by more of the dying and their doctors. And I certainly see why people think you had a way with words. We all must aspire that when your past words are read, our present suffering sick will have more attention paid to what can only be described sometimes as a wretched way of dying. It does not take much of an imagination to hope that the suffering souls in the Old and New Worlds today deserve to have better palliative care than their anguished ancestors in Elizabethan England.

Thank you, Mr. Shakespeare. Any last words about the goal of palliative care for the suffering of the sick?

All’s well that ends well
All’s Well That Ends Well

 

Comment on this article

Michael A. Salvatore, MD, FACP

Dr. Michael Salvatore was a pulmonary medicine/critical care physician for 35 years. Since 2012 he has been the physician advisor and medical director of the palliative care team at Beebe Healthcare in Delaware. After earning his MD at the University of Arizona, he trained in internal medicine and PULM/CCM at Duke University. Dr. Salvatore is a member of the RACmonitor editorial board.

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