Observing patterns of attachment over time

The privilege of observing nine month old Emma, being cared for by her mother and on occasion by her childminder, over a ten month period provided me with the opportunity to see her develop from being totally dependent on her caregivers to recognising herself as a separate person who was keen to be independent. The regular observation of Emma, both in the care of her mother and her childminder and in the company of her siblings and her peers, presented a picture of the total experiences to which she was exposed over a significant period of time.     

Building relationships and changing lives: a community health worker story

Maria Murphy is a community health worker in the south Bronx, an impoverished underprivileged neighborhood of largely Latino and African American communities along with smaller ethnic minority groups. Having come to New York at 13 years of age from her native Puerto Rico, Maria held numerous jobs while supporting her family and completing her education. Maria soon got a position as a community health worker and discovered purpose in her work. Her work with people she serves has been called a labor of love by her clients. Maria describes it as her passion. This is her story.     

The child with a hangover that lasts a lifetime

D is six years old. She is small in height and described by her carers as 'a live wire.' D attends mainstream primary school where she has learned to count to ten. Although she and her carers spend hours on spelling and reading for homework, she does not remember what she has learned. Her speech, however, is good and she can express herself well. She does not realise she should wear a coat in winter and can only understand instruction if broken into small parts. D likes to give hugs and kisses to visitors to her home. She loves everyone in school, even the teachers get a hug. Anyone who smiles at her is her friend. Everyone likes her initially, but few want to spend much time with her. Her pockets have to be checked regularly for things she finds' and at times she stares blankly when people talk to her. She has disturbed sleep most nights and likes to bang her head and to rock herself. D is described by most people who meet her as 'cute' and endearing.' The outlook for her future, however, is not promising.     

Case management for patients with rheumatoid arthritis

Mary was in her mid-20s when a long day of shopping made her feet hurt so much that she sought the care of a podiatrist. Radiographs showed no abnormalities in her bones, so it was not until several months later, when her hands became swollen and painful, that she was diagnosed with rheumatoid arthritis (RA) by her primary care physician.     

Court says mother has right to stop HIV drugs for son

A mother in Maine was charged with child neglect for refusing to administer triple combination therapy to her 4-year-old son, who is HIV positive. The mother based her decision on her own experience with monotherapy and on her older daughter's experiences of the harmful side effects of AZT. Upon her daughter's death, the mother discontinued AZT treatment for herself and her son. After the mother refused a pediatrician's suggestion to start triple combination therapy for her son, the doctor reported the mother to the Department of Human Services, who then charged her with neglect. According to Newport District Judge Douglas Clapp, the mother has shown great concern for her child, and since the relative advantages of the proposed treatment are unclear, the ultimate decision of treatment should be the mother's decision. Many AIDS advocates have stated that antiretroviral therapy has shown significant benefits and recommend that treatment decisions be reached through a trusting partnership between patients and their doctors.     

Family physicians leaving their clinic--the Balint group as an opportunity to say good-bye

The cornerstone of family medicine is the belief in both the continuity and availability of care. These beliefs are challenged when a doctor leaves his or her clinic because of personal reasons. In the example described in this article, the involvement of colleagues in a Balint group led a doctor to a flash insight into her conflicting feelings related to leaving her clinic. The group process helped her to prepare and deal with her own feelings and needs, as well as those of her patients and staff. Balint groups are a secure place to explore and gain insight into the emotional aspects of attachment and separation of physicians from their patients.     

Pseudocyesis in an adolescent using the long-acting contraceptive Depo-Provera.

A case report documents a Hispanic adolescent, 17 years of age, with pseudocyesis, who became amenorrheic using Depo-Provera to prevent a second pregnancy. Pseudocyesis includes classic symptoms of pregnancy such as nausea, breast enlargement and pigmentation, abdominal distention, and amenorrhea in nonpregnant women. It demonstrates the to control one's physical aspect at the level of hypothalamus. The involvement that contributed to her pseudocyesis--in this case, of her mother and boyfriend -- was not unusual. The abrupt resolution was brought on by normal menstrual period that began after she voluntarily missed her Depo-Provera injection. However, her ambivalence about a pregnancy became clear after she and her family received counseling. While the agenda had been to help her prevent a pregnancy, hers had not been as clear and uncomplicated. Her subsequent conception was a very positive one for her and her family, which helped to resolve the situation.     

Palpable purpura and a visible sock line

A 21-year-old woman came to the clinic, frightened by a painful purpuric rash on her lower extremities. The lesions appeared suddenly 3 days before, with no prior similar episodes. The pain, and some swelling that happened when she stood, had finally driven her to take some time off from her job and seek medical advice. She was diagnosed with a case of pharyngitis earlier that week; due to multiple drug allergies, she was prescribed a course of clindamycin. She had not experienced any nausea or vomiting, fever, abdominal cramping, or gross hematuria. On examination, the patient was friendly and good-humored, although she was concerned about her rash and visibly uncomfortable. She was walking with the aid of a borrowed cane, but her lesions were no longer tender to palpation. The rash consisted mainly of purpuric papules almost entirely limited to her legs, although some isolated lesions were on her back as well. The papules were concentrated around her distal lower extremities, with a clear line of lesions encircling her calves bilaterally where her knee-high socks had applied pressure for the last 2 days. Mild edema was noted, but the rest of her physical exam was normal. By dipstick, the patient had blood in her urine but no protein. What is the diagnosis? What is the treatment for this condition?     

Managing mental health disability in the workplace

Jane is a 51-year-old customer-service representative for a utility company's customer-service call center. She has worked in this capacity for almost 10 years. She was considered an exemplary employee, received commendations at work, and was in line for a promotion to a supervisory position. Unexpectedly, she was assigned a new supervisor. Her performance began to decline, and her relationship with her supervisor became fraught with tension. A week later, Jane filed a grievance with her human resources department stating that her supervisor was verbally abusive, humiliated her in front of coworkers, and refused to accommodate her recently developing back pain.     

Student claims school forced her to reveal HIV infection to class

A 15-year old HIV-positive student at a Catholic high school in Miami was forced to stand before her classmates and disclose that she had HIV. The lawsuit brought against the school alleges invasion of privacy, conspiracy, outrageous conduct causing severe emotional distress, negligent supervision of school officials, and violation of Florida's informed consent law. The girl did not want anyone, except the principal and church pastor, to know about her HIV status. The suit alleges that both the principal and pastor ordered her to disclose her HIV status to her classmates and teacher, threatening to disclose her status if she did not comply. It is also alleged that they threatened to take punitive actions against her.     

Nurses interacting therapeutically with elderly patients in chronic depression

In a humanist care model we searched to analyse experiences lived by nurses interacting with chronic depression patients. There was a female patient who was being assisted by Psycho-social Support Nucleus (NAP), 60 years old, presenting depressive symptoms, proper for her age, probably stressed by her suffering experiences in life. It was a therapeutic interaction as matters of the patient's interest (not the nurses interest) have been presented; the pace of communication has been determined b the patient herself; the nurse (except in the very beginning when the patient was a little anxious) followed her communication, physically approaching her whenever it was necessary; intervened only at necessary moments; inspired confidence that was necessary for the patient to talk about her intimate feelings; helped her to recover when she was out of control; conducted her safely, but with comprehensive attitude until the patient felt easy to leave her; demonstrated that she could help her in other moments if she thought it was necessary. Interaction achieved its aims helping the patient and being technically adequate for therapeutic and diagnosis aspects.     

I am a hospital chaplain who happens to be a Jewish woman

The author describes her experience through several quarters of Clinical Pastoral Education as a Jewish woman. She recounts the story of her own sense of urging toward chaplaincy as an expression of her spirituality, as well as much of the "mixed" nature of her journey among a predominantly Christian group. Included are stories of patient encounters as well as a record of her ongoing conversation with her surroundings.     

Vivian Paley as a model for moral decision‐making

In her book, You Can’t Say You Can’t Play, Vivian Paley critiques the issue of fairness in her kindergarten classroom and concludes that the behavior of some of her students is not acceptable. She proceeds to reflect, analyze and then create a plan that she believes will provide the children with the opportunity to behave fairly with each other. The process involved in producing such a plan is fraught with certain dilemmas that carry with them ethical dimensions. Paley’s story also serves to model how a teacher uses her own moral understanding as well as her understanding of child development to interfere with behavior she defines as wrong, and models the capacity of a teacher to teach ‘good’ behavior. The change of behavior that she witnesses as a result of her actions provides tangible proof that her decision was appropriate.     

The physician's responsibility in adoption, Part I: Caring for the birthmother

The unmarried pregnant woman considering adoption needs more than medical care from her family physician. She needs an advocate who can help her reach the right decision about her untimely pregnancy, advice about the options for adoptive placement of her child, and respect as the child's mother during her hospital stay. After the birth and adoptive placement of the child, the physician can help the birthmother resolve her grief and may serve an ongoing role as an intermediary between the adoptive family and birthmother.     

The “Foresty Way”: My Mother’s Brave Choice of Medical Aid in Dying

I miss my mom, who died last year, and I want to tell the happy story of her death, or perhaps the story of her happy death through her choosing and accomplishing medical aid in dying. My mom was 85 when she died, had atypical presentation of lymphoma which took time to diagnose, and went through 3 painful months of surgery, radiation, and a single horrific round of chemotherapy. She suffered a lot. When she was in the hospital recovering from chemo, I witnessed 3 amazing doctors being true to core values of their profession. But the most profound aspect and gift of the events surrounding her death was the way in which making an informed choice gave my mom back her presence—allowing her both peace and power in the end of her life.Key words: end of life, informed decision making, physician-assisted dying, medical aid in dying

My feet crunch on the rocky soil as I take the shortcut through a mini forest of about 30 pine trees that makes up the incongruous view outside my office window in high-tech San Francisco. The juxtaposition of pine trees with urban space always reminds me of my mom, who would often drive me to the supermarket in our urban community on a side street, known always between us as “the foresty way.” It was a dark, mysterious avenue of mature pines that one could imagine led to some otherworldly realm. When I got to my desk, which looks out over endless construction and these pines, I wanted to call her to tell her about today’s foresty way reminder. I miss my mom, who died last year, and I want to tell the happy story of her death, or perhaps the story of her happy death through her choosing and accomplishing physician-assisted dying.My mom was 85 when she died. She had been extremely healthy, and happily living independently in the mountains a couple of hours away from me. She had atypical presentation of lymphoma which took a while to diagnose. To treat the cancer, she went through 3 painful months of surgery, radiation, and a single horrific round of chemotherapy, and she suffered a lot through it. When she was in the hospital recovering from the chemo, I witnessed 3 amazing doctors being true to core values of their profession. Although I am surrounded by talented physician colleagues at work and I see my husband who is a family practice–trained hospitalist take good care of people, I was nonetheless impressed at their excellent care.First, a wonderful palliative care doctor with a strong spiritual energy came in and discussed my mom’s pain, the wishes she had in her life, and the ways that hospice might help her. She took her time in the visit, a noticeable shift from the hectic pace we had become accustomed to in the previous few months of diagnosis and treatment. What was most remarkable was how deeply connected my mom felt toward her and how this connection also made my mom believe this doctor understood her life—the trajectory of her life. At my mother’s prompting, their conversations led to a discussion of the End of Life Act, which became law in 2015 in California and has been in effect since 2016. The End of Life Option Act allows an adult diagnosed with a terminal disease, who meets qualifications, to request aid in dying drugs from their attending physician. My mom practically hopped out of her bed when she heard the details and that she qualified; she was so excited. She told me right away after the doctor left, “That’s what I’m going to do—physician-assisted dying. I don’t want to compete with this disease—that’s not what I want to do with the rest of my life.” I sat with her and my sadness and then, over the next few days, we set upon the logistics to put her right to choose into motion—the who, how, when, where of finding a local group to provide the medical evaluation, signing of documents, payment, etc. By law she had to wait 15 days from the time she had her first medical assessment, establishing that she had a less than 6-month prognosis and was of sound mind in the decision to choose and then actualize the dying.One afternoon during this waiting period, we were packing up her things, preparing to leave the hospital and return to her home in the Sierras. Suddenly, her oncologist knocked on the door, whooshed in, and looked her straight in the eye. “This cancer could go into remission, maybe for the rest of your life.” He took her hand and said, “It’s rare that I get to say this to my patients, but you have a very good chance of being cured.” He was clear and direct, but not at all pushy. I could see, however, that she did not return his enthusiasm. They spoke more about treatment options, what she was feeling about the next few months of being in remission, and her next steps. “I’ll give it some thought,” she demurred but her eyes had no brightness. I was not surprised. I had already felt her shift, from coping to preparing, to focusing within—it was that simple. His good intentions, openness, and clear summarizing of his viewpoint regarding her options were meaningful and deeply appreciated.Moments later, the doctor from the physician assisted–dying group we had contacted arrived. The 2 doctors literally passed each other in the hall. I marveled at how this third doctor, an emergency physician by training, gave an amazing “non-pitch.” He described the details of how the medical aid in dying process works in California—the mandatory waiting period, the 2 required medical authorizers of her status as terminal, how she would have to self-administer the “cocktail,” and that many people were reassured to have the medicines prescribed “just in case” but that only a much smaller proportion went through with it, and that was perfectly okay. All of this was easy mannered, clearly phrased—while also being kind and comforting to her. She beamed. “Yes, thank you, and how soon?” Switching to countdown mode was incredibly hard for me, but not awful. I could see she was invigorated in spirit, alternating between peaceful energy and her familiar attentive, detailed “conquering” of lists, of things to do before she was gone. I wanted her to have her own foresty way at the end of her life, so we were on the same page. Her resolve was reassuring too, as was recalling our past conversations about advanced care planning, which fully aligned with her decision. She needed my support to get through it; her dying was not going to be easy for either of us. So, we watched some cat videos and nature shows, visited with my 3 kids and husband, and we talked about the plants I would bring home from her garden. Three weeks later, she died at her house with her beloved cat, my brother, and myself. It happened very fast—I had not finished reading her the poem we had chosen, Evening by Rainer Maria Rilke, before she lost consciousness and slipped away.There is not much medical literature about how informed decision making might look at the end of life in the context of physician-assisted dying. What I have read seems to draw attention to the things that are to be avoided, like the medicalization of dying or a culture of “prolongivism,”—a perspective that the prolonging of life can create end-of-life meaning. I feel that such an avoidance-oriented view misses an important part of what was so wonderful for my mom—what was gained. In looking at the situation, one might be tempted to focus solely on the palliative care and assisted-dying doctors’ behaviors and actions, as they are the “managers” of the experience in the medical-legal context. To me, though, what was vital for my mom’s decision to feel right for her, to actually comfort her, was the oncologist’s engagement with her, even as much as she valued the other 2 clinicians’ wonderful ways of being with her suffering. The clarity the oncologist gave her through his honesty and explanation was essential to her peace of mind in her decision making, and as a result she gained her life back. She was able to “die well,” feeling content in her resolve, because she could see that she had the option to live, but it was one she could reject, because she believed her suffering would be too great. Being able to reject her treatment options because they were options, not defaults or platitudes, made it clear to my mom and to me that she was choosing her path based on her desired quality of life, not on her expected health outcomes. Because of that clarity in knowing her choices, she felt free. She could “just” prepare, enjoy her world a bit longer, and feel proud to be so brave. This is what she gained and what I gained too.     

A long walk home.: Rachel Clark, with Naomi Jefferies, John Hasler and David Pendleton. (149 pages, {pound}19.95.) Radcliffe Medical Press Ltd, 2002. ISBN 1-85775-906-0.

Faced with the diagnosis of an exceptionally rare alveolar rhabdomyosarcomain the ethmoid sinus and a very poor prognosis, Rachel Clarkset out to write down her thoughts about her cancer and itstreatment, and the effects of both on her friends, her     

The quality of a mother's milk and the health of her child: beliefs and practices of the women of Mithila

Among Maithil women there is an understanding of the relation between a mother's milk and the health of her child. Their understanding is supported by the Ayurvedic tradition. Characteristic is the way in which breast-feeding condenses so many meanings--nutritional, medical and moral--into one act. The mother not only nurses her child but also forms his character, fulfills her own personhood and perpetuates her husband's family.     

‘Transforming’ self and world: a phenomenological study of a changing lifeworld following a cochlear implant

After 50 years of being profoundly deaf, Patricia (Pat) finds her world 'transformed'-literally and metaphorically-when she receives a cochlear implant. Her sense of self and the taken-for-granted, comfortable world she knew before surgery disappear and she is thrown into an alien, surreal existence full of hyper-noise. Entry into this new world of sounds proves a mixed blessing as Pat struggles to come to terms with her changing relationships, not only with others (who now feel somehow 'different' to her) but also with herself. On good days, she is exhilarated by all her sensory gains and her feeling of being more connected with and to the world. On bad days she is distracted and overwhelmed by the intrusive noise and she is forcibly confronted with the painful reality of her own disability (past and present). The challenge she confronts is not simply the cognitive-perceptual one of learning to discriminate between sounds. Pat must also re-orientate herself and learn to cope with her transformed self and world. She must undertake a journey to come to terms with her past, present and future being. Pat shared her story with me and together we undertook collaborative existential phenomenological research, co-creating a narrative of her journey over the year and a half following her implant. This paper presents this narrative followed by an existential analysis of Pat's disrupted, changing lifeworld.