What drew you to end-of-life care?

Question: What drew you to end-of-life care?

Ira Byock: I started medical school, thinking I was going to be a rural family practitioner, and along the way because of the nature of rural family practice, I tried to learn everything, I was really wanted to be a specialist than being a generalist, I took care of a lot of people in emergency department settings and intensive care units as well as in the hospital, trying to again be very comfortable with those outer reaches of medicine. And what I found is that, while my training and experiences and skills set was helping me to take care of people and preserve their organ function, what I and my colleagues weren’t doing very well was carrying for people who would go on to die.

And often times people were dying in needless distress, not because of any mal intension or really lack of compassion on our parts but because we didn’t quite know what to do. We had never been trained, there were no mentors, there was no guidelines. But also people at home out of the hospital I would find weren’t being well cared for, and I got into this really in a very pragmatic way.

In a very pragmatic way, during my medical training when I would realize that people were literally being lost to our healthcare system. I would see them in the emergency department when I was rotating through the emergency department and training and, and I would see somebody who had waited 5 or 6 hours to get their Tylenol with codeine refilled, and they didn’t even know who their doctor was, they didn’t really have a doctor, they just came back to the clinic or, many of them are Mexican-American immigrants and, would comeback LA Clinica doctor.

And when I would see them, when I rotated through lets say the surgical rotation, I see them in surgery C-clinic, where they showed up for their appointment, and clearly had – somebody I would meet somebody who had advanced disease, a liver full of colon cancer, and again she was just there to get her medications refilled and had no – there was no glue in the system. And I began to realize we could do better than that. What hooked me was that in dealing with the those practical problems, people’s pain in their bowels and just making sure that they knew numbers to call and, that there was a nurse who could find them out in their rural California where I was training.

In doing those things, I found that often people would tell me that this time of life really had precious value for them and their family, after a death a family – I’d see a family and they’d say, Dr. Byock, this was the biggest tragedy that ever fell to our family, but you know these last weeks with mom were the best time we ever had as a family. And I didn’t have a place to put that, I culturally didn’t know what to do with that, or I would meet a patient who knew that he was dying.

And I would say, “Mr. Rodriguez, how are you today?” And he’d look me straight in the face and say, “I am well doctor, how are you?” And I thought what does that mean? Either its the morphine is euphoric, or something more interesting is happening.

So I for a lot of my career while doing emergency medicine, which I ended it up doing for 15 years, have always been supporting hospice programs and whatever community I was living in became a hospice medical director, to give back to the community and my health system, but ended up becoming really fascinated with this notion that people could not just avoid suffering or be made comfortable, but my experience some real value during this time of life, that we would consider them to be dying. And I to this day remain fascinated by that in my clinical practice and in my teaching and in my research and in my writing.

Recorded on: March 21, 2008