“Miracle Is the Language of Hope”

If I could speak in truth to my patients, to their families, to their diseases, their fears and triumphs, I would tell them that they’re spoken of deeply in rooms they will never enter. And languages littered with jargon and hospitals around the country, every dus and dawn during sign out. Sign out is the medical ritual of physicians gathering to tell your story.

It’s typically in a room tucked away from the patient wards at a round table where every day at 7:00 AM and 7:00 PM we sit and we sift through every detail of your journey through the hospital. Thanksgiving, Christmas, new Year’s, Passover, Eid. We gather rain, snow, sleet, hail. We gather every lab, every X-ray, every CAT scan, every surgery is debated.

Dissected, disagreed, or agreed upon. We study you and know you deeply long before our face meets yours. There’s even an art to sign out. We train our residents and fellows in how to distill a complex month long hospitalization into a 52nd monologue to prepare the incoming team during sign out. We ruminate, we celebrate, we vent, we cry, we bond.

But this is our ritual, unseen, unspoken, unheard by many of the patients that we care for. And although sign out is certainly a secular practice, there has always felt something very ceremonial about it. And perhaps it is because for me, in all of my years practicing medicine as a critical care anesthesiologist, my own personal prelude to sign out has been prayer every day.

Whether I’m working a morning shift or an evening shift on my drive into the hospital, I pray, and that is my ritual unseen, unspoken, unheard by many of the patients that I care for. And I pray for all of my patients. I pray for the surgeons, the respiratory therapists, the nurses, and simply ask the Lord to guide my thoughts, decision making and actions.

I unconsciously almost always fiddle with my small gold necklace that I wear to work every day. And I never imagined that this little piece of jewelry would engender so many special moments, but it has at first, patients and families would say to me, Dr. Bta SI like your necklace. And I would say thank you and just move on with my questions about their exam, or characterize their pain or break news about their horrific injuries after a motor vehicle collision.

But. One of the beautiful things about becoming more experienced as a doctor is that the more that you become comfortable with the science of medicine, the more that you can really flourish in the art of medicine and exactly that happened. And so over time in reading the room, I realized this necklace is more than just a piece of jewelry.

This is an invitation. And so my thank yous evolved from. Can I pray with you sheepishly? To what can I pray for you today as I became obedient to that still small voice to gather hands or bow heads at the bedside. My offers for prayer were not always met. With a resounding yes, let’s be clear on that, especially depending on which region of the country I was practicing in.

But that was okay and I was comfortable with the no, because working in the ICU is an immersion into the full range of humanity and the multitude of ways in which individuals meet their vulnerability. It shows up as this gut deep whale, a sound that seems to rip through time itself when life moves in reverse and a parent has to eulogize their child.

Or the paralysis that strikes when a loved one walks into the ICU for the first time and they’re met by the worrying of the ventilator, the beeping alarms, the gallons of IV fluids and artificial nutrition being pumped into a vulnerable body. Just trying to determine where do I land my fear, or the silence and the heaviness that follows after someone dies.

And with guilt, patient’s families will ask, doctor, what do we do now? And no other space has my faith become more salient than walking patients and families through death and dying in the ICU. However, faith like medicine is not always tidy. I have asked God why a thousand times I’ve questioned suffering and its forefather tragedy even more so.

But between this certainty and surrender, this blur between grief and gratitude, this tension has taught me three key lessons about how we might better understand ourselves through our patients in the sacred work at the end of life that we all perform. The first is that it’ll push us to places where categories collapse.

New York Times columnist Frank Bruney, who’s also a professor of public policy at Duke, where I work, wrote a profound book last year, which maybe some of you’re familiar with, called The Age of Grievance. And in it he describes how as a culture we’re becoming more and more defined by what outrages us and what angers us.

And I’m sure Mr. Bruney did not have the ICU in mind when he wrote this book or think that it would be mentioned at a death conference. But surprisingly, I have found the book wildly applicable. Because in the midst of grief, it’s very easy for grievance to take root against the unfairness of illness, against the failures of a healthcare system or even against the silence of God.

I can recall a young woman who died in our ICU recently, and when her younger sister arrived to the bedside, she was seething. She was nearly foaming at the mouth. She said, I’m so angry. I’m so angry. I’m so angry. Her mom said, at who? Honey? She said, I don’t know, but I’m so angry. And yet even in that anger and yearning, there was still faith.

When she settled, she scanned the room, her eyes met mine. She focused in on my necklace. I said, can I pray with you? And I was so honored when she said, I would love that. I can think of numerous instances where categories dissolve, for example. There have been families of patients who have rushed into the ICU with Confederate Flag T-shirts, and I a black physician, have been the ones whose arm they have wept into.

Desperate for reassurance, desperate for medical expertise, desperate for mercy. This truth, this blurring of categories has met me again and again, but one most, most memorable on a night shift, a few weeks back, the process started at sign out. I heard the 52nd monologue from the day team, and I knew immediately this patient will not survive the night he was estranged from his children.

And so what I was most concerned about was that there would be no one with him while he died. I was one doctor caring for 22 patients in the ICU that night by myself. I had hands to keep him alive, but what I really needed most was a human touch so that he would not die alone. So. Did what all good ICU doctors do, and I paged the chaplain on call, shout out to all the chaplains

and graciously she arrived. What within what felt like minutes and what transpired next was one of the most beautiful evenings I’ve experienced. We called his children on speaker phone and broke the bad news. There was certainly grief. There might have also been grievance. I wish I could have sat and unpacked and held the complexity of that pain.

But instead, I asked about what his joys were, what his interests and hobbies were, and over and over in different iterations, they said ministry. And so our chap, what transpired was a Jewish chaplain for a Christian pastor. Our patient, she sung the lyrics to his favorite gospel songs. She recited Psalms, his favorite scripture.

From memory, the two of us prayed Lord’s prayer for him in unison. Meanwhile, the nurse titrated his pain medications to keep him comfortable. I came in and out of the room as I was able sometimes just to hold his hand for a minute, and I wish I could have sat with them longer with the constant ding of my pager kept taking me away.

And finally, as this gentleman took his final breath, the chaplain was weeping for a man she’d never met. And I asked her at the end, what? What do you think moved you so deeply? She said, simply the humanity of it all. And I’ll never forget that night, but this patient’s story shows us that the challenge is not necessarily to banish grievance, but to understand it as a shape or a proxy for grief.

And thus, to hold it alongside compassion so that our mourning does not pose us in, but rather opens us up to connection to one another and to the mystery of what endures beyond this life. And that brings us to our second lesson, which is to leave room for your own miracle. In medicine, there are few statements more polarizing than when patients and families come and say, doctor, we are waiting for a miracle.

As physicians, we are trained in science and data and analysis and facts, and so when the word miracle enters the proverbial group chat, a lot of my colleagues are like, oh, cannot compute. But what I hear when patients and families say we’re waiting for a miracle is simply we are holding onto hope.

Miracle is the language of hope, and sometimes the miracle is that medicine. Study the body long enough so that a son flying across country can whisper goodbye to his dying parent, or that there’s an unexpected lucid interval after days and weeks of immobility and silence and a patient opens their eyes.

One final time to receive, and I love you. We don’t always understand why some patients die and others don’t. But these special moments which happen in hospitals across the country, across the world, every day are sacraments of hope. Where faith meets science, there are a window into the small ceremonies that we all perform each day to maintain our humanity in the face of life’s dehumanization.

They rewire us from traditional medical training that says that faith in medicine are opposing sort forces when in reality they’re often synergistic. For my science people stay with me. Now, there are several randomized controlled trials which have looked at the impact of prayer and spirituality on patient’s pain perception ranging from postoperative recovery after C-section to electrical stimulation to major abdominal surgery.

And across all of these domains, patients consistently report lower pain scores when faith practices are incorporated into their care plan. And so that brings us to our third and final lesson, which is that. Maybe spirituality isn’t necessarily somewhere we go. Maybe it’s something we do again and again in the many altars of our modern life, we all tend to think that spirituality belongs in pews and mosques and temples.

But if you look closer, ritual is everywhere. You have all perform ritual today. Some are small and quiet. The daily ritual of brewing coffee, the pace rhythm of a morning run, the tending to gardens or houseplant. Or the playlists and songs that we all return to when words fall short. We look to these rituals to fill our cup to.

Pour a certain fulfillment back into our spirit in the same way that spiritual practices like a family gathering to keep Sabbath or to break a Ramadan fast, or an individual traveling to a silent meditation retreat or attending a wonderful conference like unwell are all seeking to be healed and transformed.

So whether you call it prayer or wellness, we’re all kneeling and showing quiet reverence to something, and at the end of life, those somethings reveal themselves in loud presence. And so ultimately what? Ultimately what I’ve learned after walking countless patients through death and dying in the ICU is that in the hospital even the most basic rituals that help us maintain our humanity are stripped away.

The scent of coffee is replaced by antiseptic, the favorite meal morphs into puree. Even the act of choosing one’s own clothes are all surrendered at the door. So in my ICU, we try to reimagine these rituals. I explain to families that. During death, the sense of hearing is usually the last of the five to go.

And so I encourage them to hold their patients, speak to your loved one, play comforting music, or tell jokes or read scripture or read songs that they enjoyed. And over time, solely, we hold vigil. Music becomes liturgy. Art becomes scripture, and the act of holding one’s hand becomes communion. And so truly any room if you allow it can become a temple.

Any gesture if offered with love, can become a rite of passage. So at the end of life, whether at the bedside or at home or in the hospital, we are not just holding someone’s body, we are holding an altar. In death, we will all face that same wilderness and in that wild space between divisions and grief and anger and categories, what will remain, what will sustain us is not certainty but hope and hope.

Is the greatest miracle of all. Thank you.