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Well, first I've got to tell you the reason i am here. Actually, I can't believe i'm here!
I'm a doctor graduated at "Casa de Arnaldo" (São Paulo University) and in college, since
the beginning, i was interested in something that most people weren't. And it was very
hard for me to practice medicine in the first years, because i used to see things very different
from what people used to say they were like.There is this poetry from Manoel de Barros, which
in a way defines myself. It says: "she doesn't see the egret on the edge of the river, she
sees the edge of the river on the edge of the egret"; That's how i used to see things,
in a way that i would have to "dispractice" the standards or the rules, as Manoel de Barros
said in his poetry. So i "dispracticed" the standards because started to take care of
people who were in the end of their lives. The other interns kind of hated me because
I used to let my beds at the hospital full of dying patients and that made me understand
that medicine had a lot to offer to these people, contrary to what most said. They said
that palliative care patients were those who medicine can't help. When you, as a doctor,
can't do something in order to save your patient, you give him to palliative care, they said.
So the second hardest part of what i was doing was to work with palliative care, whereas
in our culture it is seen as "patch". Palliative care is not about fixing a loose wire with
an adhesive tape. It is much more than that. The word palliative comes from Latin word
"pallium" and it means mantle, blanket; it was a cape used by the Crusade Knights to
protect them from the bad weather; and this has everything to do with my work!
I work with palliative care, which is protection care. Protection care against the torment
caused by a severe, incurable and out of treatment possibilities disease. A disease that threatens
the continuity of life and will lead the patient to death for sure. When we talk about this
long definition, we talk about the terminality that everyone associate with time... "that
patient has less than 6 months to live, he's a terminal patient", " she has a week, terminal
patient". The terminality has to do with this concept: is a severe disease thas is progressing,
is following its natural course and what it will cause the unfortunate circumstances that
we call suffering. The diseases is an abstraction of reality,
it's on the books, it's on the microscopes, it's in thedefinitons, in the publications.
But when a disease meet a human being it produces a unique melody that is called suffering.
The diseases repeat themselves on people, but the suffering doesn't.The suffering is
sole, each one has his.And the suffering has five different notes, five different frequencies.There's
a physical pain that has a huge noise that is so loud that you can't hear all of the
other sounds of the human being. On palliative care we treat this physical pain as an emergency,
since it's life threatining. If you can't treat this physical pain, there's a lot to
do about the control of other symptons. And then you go to the emotional dimension that
has a much more complex note, a Bach's quality type, very complex, very rich.Medicine is
very easy folks, Psychology is the hard thing. Each human being is unique and will express
a t this moment the awareness of their finitude... Because everyone in this room knows that were
all going to die, don't you? Is anyone shocked about it? It's not a surprise, is it? You
just don't think that it can happen in two weeks from now if you get shot for example...And
when we talk about the emotional dimension comes all the complexity to understand and
search for the reason for this to happen. In all palliative care books, they separate
the social dimension in four pieces: physical, emotional, social and spiritual suffering...
I'm kind of cocky so i separate the social part in other two: the family and the social
dimension. Cause the truth is that we never get sick alone. We get sick with our family,
and we are part of our family and then we become a patient in our family and after we
die there's a hole in this situation... and we need to take care of it...And the spiritual
dimension is fundamental since it will give us the essence of being human. Spirituality
doesn't have much to do with religiousness. Religiousness is just a path to reach spiritually.You'll
find the spirituality in the way you relate to yourself, in the way you relate to the
other, in the way you relate to the nature, to the universe and to God...There's peple
that relate to the universe and have no relation to God. It doesn't make their spirituality
less important. We seek for meaning in our existence, there has to be an answer.And then
we accept "any how" as Nietzsche said. Palliative care will take care of people suffering
in all of these dimensions. So, contrary to what most said, palliative care has lof of
work to do. We work a lot because when i look at a patient i can't be frustrated cause he
has an incurable disease .If i became a doctor to take care of people i won't be frustrated
if their diseases don't have a cure.But there's a lot of people that become doctors to treat
the disease. There's nothing wrong with that, you just have to be clear of this choice.
And then, when you say to the patient: It will be okay", he will read in your eyes:
" Everything went wrong" ...This frustration is understood by the patient as: " there's
nothing they can do to help me". We should think about the meaning of time
when we talk about palliative care.In order to understand the importance of this job we
have to realize that in a situation like this (photo), when you are on the clinic at nine
o'clock in the morningand you are going to see this patient, she prepared a lot to be
in this appointment, she prepared for about three or four months waiting for this moment,
she will have about fifteen minutes, maybe less time that i have here to tell you what
means the importance of this story.She will have fifteen minutes of the doctor's atention,
she is preparing for three months thinking of what she has of more important to say in
these fifteen minutes, because in these fifteen minutes also must have room for what the doctor
is going to say to her.She is prepared, she's wearing an earring, she put on a new dress,
she's wearing a hat...The person who is going to seat on the other side is prepared for
this? Is he giving the same importance as her? Because the time that they are going
to exchange is the same... Fifteen minutes of his life the doctor will give, and fifteen
minutes she will receive... But there's a difference between the two characters on this
scene: she doesn't have time to waste. The person who is going to seat on the other side
have to understand that she doesn't have time to waste with someone who doesn't care about
a human being until the last minute of his life. It's not possible that we can't offer
that to a person who is much more than a body, much more than the biologycal dimension.
When we talk about statistics we know that in Brazilmore than one million and a hundred
thousand people die every year. We are going to be partof these number at some point of
our life... at some point of our life someone who we love will be partof these number. About
eight hundred thousand people in Brazildie of an announced death, they die of chronic
and degenerative diseases or câncer.
This announced death provides the person the chance to resize his own existence and to
understand in which steps he wants to walk.And if there's someone on his side who comprehends
a table, a statistic, who has a scientific training -- cause science is brilliant guys,
it's a wonderful thing to be a scientist, since you get the chance to discover lots
of things... you can offer amazing things to these patients...And there's an interesting
feature about science, everything you reproduce has quality. If you treat a million people
and have the same outcome, this is science, this is evidence-based medicine.But when you
talk about art folks, it's quite the contrary. If you reproduce art you have piracy.And the
human being is unique, he's not reproducible, he's not replicable.
So you have to find the best thing about science and about evidence-based medicine. Cause there's
a lot of consistency and technically well-done things inside palliative care. You have to
gradute and understand the importance of all that in order to offer the patient the best
so he can make a very good use of his life. If there's anything ethical inside palliative
care it's not do to others what you wish others would do to you, this is silly... you'll do
as if it was for YOU! The most ethical thing we can do in palliative care before a dying
patient is to listen him the way you would like to be heard.That's how you're going to
understand the meaning of being part of a statistic when you hold the hand of a person
who is partof these numbers. Many people ask me if this is morbid, if it's
hard to work so close to death..."wow, your job is the most beautiful thing, but it must
be very hard, isn't it?" I'll tell you what: this is one of the most incredible jobs inside
medicine because you're never worn out. Contrary to what people who study Burnout syndrome
say, that doctors who work with palliative care and terminal patients have high rates
of exhaustion, we have not! This is a lie! People who work with dying patients do have
high rates of stress, cause they don´t have a clue of what they're doing there. But people
who work with palliative care feel quite the opposite, cause we learn the value of life.
We're not death's apology. Death isn't pretty. It has the unique beauty of sorrow, but itisn'tpretty.
Life is beautiful. And when you walk inside an office like that one, seat on that chair
and look at the patient, look at that person in a different way, as Chico Buarque says:
" in a different way that you've never done before, in a warmer way that you've never
used to look" ...that's when the patient realizes that someone believes in him, that he'll be
able to handle it,that he does have just a little time but there's someone on his side,
someone who will treat his symptoms with the same respect, dedication, devotion and determination
that he would treat a cancer or a heart disease.And at the time you relieve his physical symptoms
he'll get the chance to handle everything all of us have to handle in life and we tend
to let it to the final minute. Is someone here ready to die today? Don't even raise
your hand causei´ll have to refer you to a psychologist. Nobody is ready guys! Everybody
has something to do and let it to be done when you're leaving... wear a lipstick, comb
your hair, piddle... you know? Just like you do before you're going to travel. It's like
this with every human being. We have the illusion that the first impression
is the one that sticks. It's not! The last one is the one that sticks!Because it's impressive
how everybody shows their human essence in the end of their lives. This is the state
of lovingness. It´s impossible to describe the generosity of these people delivering
wisdom, knowledge and gratitude to us who work with palliative care. And that's when
we're going to experience moments of pure joy especially because sometimes patients
can separate their joy in two: the one ofliving that moment without pain, and the one of living
the moment when he can ask for forgiveness, reunite with someone he loves a lot, and say
thank you.He'll live this once and will be very happy to tell you that he could do it.
He says: " you believed in me and i've done it".So you'll be able to resume ties, reconstruct
situations and understand your existence in a way that in the end makes all sense.Cause
we know that in the end of a book we'll understand things that we didn't in the middle of it.It'sthe
same with a soap opera or a movie. In the end everything makes sense.And if we're not
in pain, not breathless, without discomfort, fear, guilty and abandonment we'll be able
to understand the meaning of all that. This lady (photo) was one of the people who taught
me best.We were together for 3 months. When i step inside people's lives it's not a pleasure.
It'snot a pleasure to meet Doctor Ana Cláudia, it's really not.First of all, i'm a geriatrician,
so i show myself in a moment of life that no one loves to be in.And then, when i do
palliative care it's not a pleasure because i enter through a door that everyone wants
to keep close, the door of sufferring, of diseaseand of death.But once i enter i start
to be part of that patient and that family's lives very sorely. And there's no other way,
we're human beings and we exchange and the learning that we receive is some thing we
can't describe. When she passed awayi got the chance to say goodbye and it was very
special because at the exact moment she shed a tear, i shed lots of them, but she shed
just one.And a tear that drops from the eyes of a person that got the chance to be free
from physical pain, that got the chance to be free from fear, from guilty, fromthe lonelinessof
being in this moment, to have to pass through this moment alone, got free from the abandonment,
reunited with her family, was there for everyone most ofthe time, was admired by people for
her courage to deal with her end, and then that tear droped. It was a sad tear, but it
was of a genuine sadness, don't you agree?There's no other way, we do get sad! But it's a pure
tear, of the essence of a life that met its existence and was saved.That'swy when i talk
about palliative care i do talk about saving lives, but we save historical lives. Life
with a capital L, not a body, not a disease that has a cure, but a chance to fly on first
class. In this life here, no matter what your religion, you only die once, so itcan'tbe
a shame. If we get the chance to meet doctors that really care about our time, about the
importance we give to our time and put as a priority of their work what we determine
we'll be very lucky.Andi have to say that i'm very happy to be here and know that there's
people that can believe that death is a day that isworth living. Thankyou!