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Conversations That Should Not Be Delayed

fig 1“When you were born you cried and the world rejoiced.  Live your life in such a way that when you die, the world cries and you rejoice.” ancient Sanskrit saying

The year 2013 has seen some big wins and some big losses in my personal and professional life. These events (mostly the losses) reinforced a lesson about the importance of certain crucial conversations or perhaps the value of not procrastinating in these conversations. The conversations were different; one personal and the other professional. However, both relate to tending critical relationships. Both conversations also have in common the fact that they are often the subjects of delay and then the opportunity is gone.

The recent loss of my father, Lawrence T. Archer, and a dear patient, Naome Chiri, within two weeks of each other, reminded me of the value of tending relationships, keeping them fresh and up to date and leaving no important truth unspoken. I offer a brief account of each experience in hopes of inspiring others to have those timely conversations with their parents and their patients. The suggestion is that having these conversations yields peace while delay or omission leads to regret.

As an Old Timer hockey player you know the rules of hockey: you win some, you lose some, but you should always leave the ice with no regrets. In hockey you have no regrets when you give your best and bring all your abilities to bear on the game. Take your eye off the goal and you are liable to have the regret that comes from missing a scoring opportunity. As a son I know about the importance of my parents but it is often easy in the course of a long work day to assume they will always be there so that I can tell them how much I love them or what certain life events that they were part of meant to me. Amongst the many things I undoubtedly failed to do as a son, there is something I did right, which might be worth sharing. In April 2006 I took two weeks off to realize one of my father’s lifelong wishes: to drive across Canada. As a flight engineer in the RCAF, he had crossed the country many times by air but he had not had the chance to see it at eye level. We set off from Vancouver Island and stopped at dozens of places across this beautiful and expansive country. Many of the stops brought us to the homes of old air force friends. The conversation we had over those two weeks was not profound but it was invaluable for me and I think for him too. We talked about his childhood, his time in the air force, about food and music. I got to tell him how important he and Mom were to me. Now, these conversations were not new….we had a strong relationship before the trip and I have always talked to my parents regularly, daily as I matured. However, having been away from home since age 18 it was nice to have that conversation at a point in life where I was comfortable enough in my own skin to thank Dad for being my role model, an inspiration and to say, man to man, that I understood what he had done for me and for the family.

Fast forward through several years and several strokes and I am at his bedside.  He is unconscious. Suddenly and irrevocably unavailable for conversation. At that moment it would have been too late to say these simple things I said as we rolled through northern Ontario. I recognized in that moment how glad I was for the daily phone calls, most of which were simple and dealt with day-to-day life events, and for the big TransCanada conversation. I shed some tears for Dad when I delivered is eulogy; however, as emotional as this was, there were no tears of regret. Only the tears related to losing a friend, guide and person I loved. So, my first conversation can be filed under the heading, “talk to your parents regularly and recognize that the moment when that last conversation will occur is unknown”.

In my capacity as a physician, I experienced the next week, the loss of a dear patient. Naome had a big heart, in both a cardiologic and a metaphysical sense. This immigrant nurse from Zimbabwe was referred to me for heart failure and pulmonary hypertension. She had a history of an untreated atrial septal defect, astutely diagnosed by Dr. Christine D’Arsigny (right).

The challenge for me was whether his hole in Naome’s heart could be safely closed, and whether this would alleviate her progressive shortness of breath and fatigue. We had many conversations in clinic about the risks and benefits of surgery, but more importantly we talked. These conversations established a relationship. We talked about Africa, nursing and her family. Naome was always accompanied by her wonderfully supportive daughter, Christinah (who allowed me to tell her mother’s story). I told Naome about a rotation I had done in Kenya as a Queen’s medical student, working at Kenyatta National hospital in Nairobi in the late 1970s. “Oh, Dr. Archer, you have seen my people”, she gushed flashing her warm smile. So was trust established. Finally the decision was made and the surgeons agreed to operate on an ASD that was too large to be closed percutaneously. The week of my dad’s final stroke I was buoyed by learning the surgery was successful; all was well.

Then two sudden and unpredicted postoperative complications, unrelated to the closure: a pulmonary embolism occurring despite heparin prophylaxis and a sudden arrhythmic death. Naome was in extremis. Standing at the bedside the week after losing my father, I was talking to Naome’s extended family discussing withdrawal of life support, encouraging an autopsy and sharing in their grief. After Naome died, Dr. D’Arsigny and I met with Christinah to review the autopsy results and to reconnect. This was an important conversation. Christina’s generosity was humbling. She brought gifts for us and showed us some of her favourite pictures of her mother. Her main fear was that her mother would be forgotten. She was relieved to hear that the surgery had been without flaw, despite the results. There was no regret about having done the procedure. She understood from her own astute observations and the frank conversations we had pre and post operatively the necessity of action. Christinah was grateful for the care her mother received, despite the outcome…she just wanted the story of her mother to be known. The conversation that day in my office was about her Mom, working as a nurse in Zimbabwe, sacrificing herself to ensure that her children had a good education. It was about her Mom helping them to emigrate and make a new life in Canada. The final eight years of Naome’s life were lived in Canada and during those years Christinah had the same kind of daily conversations with her Mom that I had with my Dad. She had  taken the chance many times to tell her mother how grateful she was for the life she had been given. While the grieving may continue for a time, Christinah was at peace with her mother’s death, as am I with the loss of my father. This peace in loss exemplifies the virtue of making times for these key conversations.

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 In memoriam: Lawrence Truman Archer

So the message I would like to share with those of you who are not as far down the road as I am, for those whose parents seem healthy, for those of you who are busy on service, caring for the loved ones of others is: take the time for life’s important conversations. Let your parents know how you feel and make your gratitude known. It is not a one-time conversation; it needn’t be grandiose or emotional. But in the end, the summation of these conversations will give you the ability to let go knowing that you have said all that needed to be said.

Likewise, nurture conversations with patients that reveal a little of you to them and vice versa and don’t shrink from conversations when outcomes are poor or when mortality is in the offing. Should the time come when the difficult conversations about life and death are required, knowing each other as people is invaluable. Patients and families deserve and are grateful for physicians who come to the bedside and engage them in honest communication around the difficult subjects of adverse events, mortality and end of life.

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In memoriam: Naome Chiri

Naome was born in Zimbabwe into a family of 9 children. Naome was a kind and dedicated nurse who worked in this profession from 1963 until she retired due to her medical conditions in 2002. Naome emigrated to Canada in 2005 to join her daughter. Although she never worked in Canada due to her medical condition, she remained a nurse at heart. She passed on Oct 24th 2013. Naome was predeceased by her husband and two of her children. She is survived by 4 siblings, her devoted daughter, Christinah, Christinah’s husband and their 3 children. Naome will not be forgotten.

Wishing you and yours a safe and happy holiday season.

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Dr. Archer, Dept. Head
Dr. Archer, Dept. Head