Rapport Report

By: HPMFellow

Few things feel better than making a genuine connection with another human being.

In the palliative world you have the opportunity to do this quite frequently. I don’t forget that I’m in that place of privilege. But every so often the rapport you establish with a patient or their loved one can backfire when someone is experiencing grief in an unhealthy manner.  It’s times like these that having a handle on good self-care and setting emotional boundaries may provide relief from burn-out.

A recent encounter I experienced with one of my home palliative patient’s daughters has left me in a reflective state about the risks and benefits of establishing good rapport. When I met this patient and her family it was clear to me from the onset that my patient had reached a comfortable place of acceptance with her advanced disease, and that most of my palliative energy during home visits would be expended on helping guide the primary caregiver through this challenging journey with her mother.

I must admit – there were certain identifiable characteristics of this woman who I believe allowed me to particularly amplify empathy to her. She was a woman who obviously cared deeply for her mother, a woman who was self-sacrificing, and a woman who was openly self-deprecating in her neurotic tendencies. This woman reminded me of my own mother. My mom was the primary caregiver for her dying grandmother several years ago and I witnessed first-hand how her deep engrossment in my grandmother’s care affected her relationships with siblings, her family life, and at last her own health.

The day I met this daughter I recognized that she had already felt these pangs – “I just got into a fight with my brother – I know I shouldn’t have done that in front of Mom,” “I’m running late to pick up my kid from the dentist,” “Oh, that must be the plumber at the front door.”  After meeting with her and the patient together, I asked how she was taking care of herself. “Not at all” was her honest reply. I said something to the effect of minding her self-care, and she genuinely expressed gratitude for this recognition. I walked away from the house feeling like I had just had ended a Friday with a “good encounter.”

I guess I forgot to recall that people with anxious propensities can ride a tumultuous course of feelings. It should not have come as a surprise then that I may be the target of her next emotional tide when I called to check in the next week. A seemingly benign, “How are you doing?” was returned with the following exchange:

“Not good. Yunno, doctor – those medications you stopped last week, I should have never stopped them. I shouldn’t have listened to you. I took my mom to see the cardiologist today, and he’s livid. My mom’s blood pressure is up, and she might have a blood clot in her arm!”

“A blot clot? I don’t believe we stopped any blood thinners. I’m sorry to he-“

“No, it’s more than I’m sorry. I have to go!”

Crushingly perplexed, and a bit wounded I quickly reviewed my patient’s electronic chart. After all – I’m still a physician learner – maybe I had a horrible mistake. The chart confirmed that I had discontinued an antidepressant the patient felt wasn’t helping her, a bisphosphonate, and a statin. Though this patient had a life expectancy of less than 6 months and wouldn’t immediately benefit from these medications, I had checked with an attending and the now alleged livid cardiologist prior to stopping them.  I left a message with this specialist who denied being upset. The patient didn’t have a blood clot. Knowing that what I had done medically hadn’t caused the patient or her family any physical harm I next reviewed in my head what I might have said differently to provide anticipatory relief from panic. You might imagine that exercise was futile.

That day I spent some extra time re-centering my focus before getting in the car to my next destination. I couldn’t immediately pinpoint what had jolted me so, but I’m happy to say I was self-aware enough not to trust myself behind a wheel without a time-out and a latte.

What I have taken away from this experience is not that I shouldn’t allow these human connections to occur (it’s one of the hugest perks of the field,) but to not let them influence my expectations of human behavior.  It’s surprisingly easy for me to forget that the emotions and actions of those I encounter are unbridled and subject to rapid transformation, particularly when it comes to topics of life and death, particularly in the home setting. I think one of the biggest adjustments in transitioning from a family doctor in a clinic setting to a palliativist in the field is not the expectation that my patients won’t experience transformation, but I won’t observe it happen over a course of many years. The concentrated dose of emotions is as frustrating as it is rewarding.

My next telephone exchange with the daughter also happened to be during a moment of crisis, but her tone had changed to one of calm and gratitude. I didn’t let the prior exchange sour my satisfaction of being of service, but I also suspect that she’ll not always be so composed in the future. And it will probably have nothing to do with my medical skill or rapport, but because she is human and try as we may, we can’t prevent or anticipate all sorrow.

As I continue to reflect on my professional relationship with this daughter, I recall some advice from a mentor I once had thought was callous – to paraphrase, he told me that at the end of day the patient’s problem/illness is their own, not yours. I’ve come to realize that the wisdom of these words does not come in cautioning against connecting with other humans, but in recognizing that you enter and leave their lives for only a brief second, and that your opportunity to connect is meant to provide guidance, not ownership of their feelings or actions.

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