The thing I appreciate most about sacred moments is how spontaneous they are. Most often I’ll be rounding, just going through my daily routine, and then the opportunity unexpectedly coalesces. Seeming to start as a whisper from someone’s mouth during an innocuous interaction, the moment just seems to hang there waiting to be captured. Like an ember that needs to be nurtured; sometimes we’re able to identify and grow it into a flame, other times we may not recognize it at all and it winks out. It’s not something that can be forced - you can’t say, “I’m going to round and spend an hour per patient today, talking with them until I conjure up a sacred moment.” Instead, I think when patients provide the opportunity, we as physicians need to be vigilant and recognize the ember they put out there, thoughtfully tend it … and the sacred moment is the flame that comes forward, warming both patient and physician alike.

Beyond observing the unpredictable nature of sacred moments, I hadn’t initially recognized they could also be bidirectional. From the physician’s perspective, we’re accustomed to being the one providing care; we want to be the giver, the counselor providing insight and reassurance - that’s very comfortable for us. However, the most impactful sacred moment I’ve experienced was the complete opposite.

I had a situation where I was attending on the medicine teaching service in the Veterans Affairs hospital, caring for a 90-year-old Veteran named Mr. G. He was highly independent, living at home with his wife, and at the time did not have any active medical problems until requiring admission for acute abdominal pain. Mr. G did have a known condition called aortic stenosis, diagnosed years ago, but he and his family deferred open-heart surgery given the significant surgical risk and only a mild impact to his daily activities at the time. Of note, since that time a new treatment had been developed for patients with aortic stenosis who are too high risk to undergo open-heart surgery.

In caring for Mr. G’s abdominal pain, we diagnosed him with a gallbladder infection, which we treated with intravenous antibiotics and supportive care. His abdominal pain and fever quickly resolved and his labs normalized. Given his rapid and dramatic improvement over the next few days, we started rediscussing his aortic stenosis diagnosis (which had unfortunately progressed to become severe) and explained this new procedure to Mr. G. He and his family were quite interested in this minimally-invasive procedure that could change his life, so we consulted Cardiology and laid out plans for the work-up required once we got over this little gallbladder problem. It was simple - all we had to do was place a gallbladder drainage tube, wait a number of weeks for things to heal while on antibiotics, and then we’d be well on our way to scheduling this brand new heart valve procedure, giving Mr. G a new lease on life. Every day in going in to talk to Mr. G we were all living in a world three steps into the future; beyond a simple tube placement procedure I’ve ordered dozens of times. All was well.

The day Mr. G was to have his drainage tube placed, our team was on call for medical codes. There was nothing out of the ordinary when we rounded on him that morning, and he was getting ready to go to Radiology for his procedure – he was one of the first of the day. We continued to see our other patients, like any other regular day, and on our way back to the team room an overhead medical code announcement was called in Radiology. My heart instantly sunk… I knew deep down it was Mr. G.

We took off on a sprint, ran down the stairs, and when our team arrived the radiology staff were performing CPR on Mr. G, as he had become unstable shortly after the tube was placed in his gallbladder. His blood pressure rapidly dropped and then his heart stopped beating altogether. As with many medical codes, things were hectic but coordinated. We were following our medical algorithms with the support of the ICU team, anesthesiologists, and nurses. Unfortunately, we were never able to get Mr. G’s heart to restart, and the resident physician, who was on the phone with Mr. G’s son, called out to halt CPR after 30 minutes as his family believed further heroic efforts were not what he would have wanted. Mr. G was pronounced dead. His family, including his elderly wife, were on their way in to see him and I knew we owed them a thorough explanation of what happened. Mr. G had unfortunately become septic when they punctured his gallbladder, causing his blood vessels to become leaky and heart to beat very fast, resulting in hemodynamic collapse, as his heart could not push enough blood through his small aortic valve.

When Mrs. G came in with her family, I was a mess inside. I could easily explain what had occurred from a pathophysiologic perspective, but had no answers for the expected “How could you let this happen?” questions. Delivering bad news is something I have had to do many times, but this was different. We had a more active role in determining what happened and when to Mr. G – this was a more complicated answer than the usual “I’m sorry but we did everything we could.” I found myself doubtful and embarrassed inside, thinking “Did we really do everything we could? What did we miss?” We took Mrs. G and her family up to the lounge area, and I remember her sitting down across from me – calm and collected. I got through my explanation of the facts in an organized, informative way, but then afterwards I decompensated into an effusive sympathetic mess. I must have said that I was sorry a dozen times, Monday morning quarterbacking every decision we made out loud. Mrs. G. just sat there quietly letting me ramble on and on, talking through it out loud – I had failed them.

I didn’t realize it in the moment, but as I was laid bare, vulnerable, and exposed – I was putting the ember out there. I remember her letting me finish and then staying silent for a few seconds, the room dead quiet. Then she put her arm on my shoulder, looked me in the eyes, and said, “Thank you and the team so much for all you’ve done for my husband. He had a long wonderful life and he’s with God now – which is right where he wants to be.” I was shocked. How could this be? She went on to say “You treated him so well when he came in and you made him better, relieving his pain. However, you can’t control everything and I know all of you gave him the best care possible.” She fanned my ember into a sacred moment I will never forget.

When Mrs. G gave me that reassurance and wisdom, that ember blazed into a sacred moment that warmed me in a way I had never experienced before. To know that she understood and accepted that I was human, doing the best that I could in an imperfect world, and reminding me that her, Mr. G, and I were aligned in what we were trying to accomplish meant so much, even if we didn’t get the outcome we all wanted so badly. That said, please don’t misunderstand - it didn’t take my emotional pain and frustration away by any means; the defeat of that day would linger with me for weeks. However, in receiving her blessing I could now use this as an experience to build upon, helping shape and hone my practice for the next patient instead of allowing it to weigh me down forever.

It wasn’t easy putting that ember out there, but I’m sure glad I did. Having this experience invigorates me to do everything I can to recognize when my patients and colleagues are doing the same – as that is how we can truly deliver the best care possible.

From a Tiny Ember to a Sacred Moment

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