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The Differential

Let's Embrace Ensō

Amanda Xi, Medical Student, 01:15PM Sep 16, 2013

“Ens˘” is a symbol that literally means “circle” in Japanese. Metaphorically, it can mean a vast number of things: the beginning and ending of life, existence’s interconnections and boundaries. It is composed of a single stroke but captures the complexity of infinity.

In “The Ultimate End-of-Life Plan,” the author describes how her mother “fought” the medical system to ultimately die on her own terms. Although death is an inevitable destination for all of us, it remains a rarely discussed matter. This leads to an all-too-familiar situation in the hospital when an individual has suffered a debilitating event and a family member must suddenly make decisions of life and death. Continue the forceful oxygenation via a ventilator? Provide rib-cracking compressions and traumatic electrical shocks when the monitor no longer registers a signal? To be or not to be?

Perhaps all of us should embrace ens˘ when discussing end-of-life matters with our patients. In medicine, we must accept that there is a circle of life. Each and every one of us will complete the cycle at one point or another, but the question of how we meet our demise has been tampered by technology. Instead of whispering our last words to loved ones and slowly fading away, we are hooked up to invasive machinery to monitor and sometimes jolt our electrical system back into an appropriate rhythm.

I applaud Ms. Butler’s adamant request to refuse a complication-ridden cardiac valve surgery. She exercised her right to autonomy and ultimately fell prey to her disease, but it was on her terms. According to the National Hospice and Palliative Care Organization (NHPCO)2012 Facts and Figures: Hospice Care in America, 74.2% of patients’ pain was brought to a comfortable level within 48 hours of initial assessment and 73.9% of families rated the quality of hospice care as “excellent.” Yet, only 44.6% of all deaths in the U.S. were under the care of a hospice program. While this number has been trending upward, more work and discussion needs to take place to ensure that patients pass comfortably and not in a strange corner of a hospital.

I remember watching a woman pass in the ICU; after a long discussion with the family about her prognosis, they finally decided to let her succumb to the cancer that had ravaged her entire body. Since I started in the ICU, she had been on a ventilator and had never spoken a word to our team. She had an arterial line and a central venous line. She was covered in bruises from where heparin had been injected subcutaneously. As her family filtered out of the unit after the monitors flat lined and a physician had called her time of death, I couldn’t help but wonder if she was at peace. Did she ever imagine that she would pass in a strange room overlooking a busy road? Did she have a chance to say all of her goodbyes? Was she ready to die? 

Let us be the generation of physicians that encourage our patients to paint their own ens˘.

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Medical school and residency can be a stressful, demanding time. These medical students share their insights and experiences, good and bad, in order to create a community of support and understanding for medical students everywhere.

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  • Amanda Xi

    Oakland University William Beaumont School of Medicine, Rochester, Michigan

  • Alexa Mieses

    Icahn School of Medicine at Mount Sinai, New York, New York

  • Casey Sharpe

    University of Texas Medical Branch at Austin, Texas

  • Carl Streed Jr

    Johns Hopkins University School of Medicine, Baltimore, Maryland

  • Matt Wiepking

    University College Cork, Cork, Ireland

  • Rick Pescatore

    Philadelphia College of Osteopathic Medicine

  • Sara Teichholtz

    Medical School for International Health, Be'er Sheva, Israel

Olaseni Ajibade

Mercer University School of Medicine, Macon, Georgia

Bryce Krishna Cragg

Texas Tech University Health Sciences Center, Lubbock, Texas

Zoyah Thawer

McMaster University School of Medicine, Hamilton, Ontario, Canada

Abraar Karan

David Geffen School of Medicine at UCLA, Los Angeles, California

Annie Chiu

Albany Medical College, Albany, New York

Felix Lee

University of Kentucky College of Medicine, Lexington, Kentucky


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