My grandmother had a beautiful garden that she expanded through years of effort in her terraced backyard. Despite rocky soil and areas of deep shade, her flowers blossomed, and the garden thrived. I do not know if her skills as a gardener were innate or learned through trials and failures, but I know my garden could certainly benefit from her guidance now.
In the medical field, there is a long-held misconception that by referring a patient to palliative care, a doctor risks stealing their patient’s hope. As if by uttering the name “palliative,” they are calling forth the grim reaper with his scythe to cut down the hopes and dreams of the patient and their family. In truth, I see myself not as a reaper of hopes but as a tender in the garden of a patient’s hopes. Palliative medicine, as a specialty, has the unique perspective from which we can combine the medical realities of “where we are now” with where our patient hopes to be. I seek to know from my patients what they value in their lives and what their wishes are for their future selves as their health changes. It is crucial to know what they hold as most important to themselves—do they prefer wildflowers or well-trained roses? With this information, I can help them kindle the hopes that are most likely to bloom, just as a gardener must select the seeds that are able to flourish in the given growing conditions.
Historically, we medical providers, with no ill intent, have often left our patients hoping for things that we know are unlikely to come to pass. And from this fear of taking hope, we leave it only to allow it to wither on the vine. By avoiding hard conversations and allowing our patients to pour their energy and limited resources (be it time, strength, or faith) into a goal that we know will be unlikely if not impossible, sometimes we set people up to realize only too late that the way they would have hoped to spend their final days, weeks, or months would have looked very different from the way they did spend them.
I have often wished to grow a garden of peonies and dahlias and have expended time and effort on failed attempts only to later understand that the conditions would never have allowed these flowers to flourish. It is sometimes when one’s garden of hope is struggling the most that perhaps I can serve another purpose of palliative care: that of support, of consolation. When my grandmother became ill due to the combined complications of a failing heart and kidney disease, she was offered the option of dialysis, which was proffered with the hope “of more time.” Yet, in holding closer conversations with her, she was able to express her preference for being home and avoiding more trips to doctors and the hospital, which would have been necessary to support her with dialysis. So, in this letting go of the hope of more time, we could support her in her wish to spend her final days at home surrounded by her large family, enjoying her garden. We have all had dreams that we have had to let go. But when these dreams are matters of our bodies or even of our life, releasing a dream can feel terrifying, as if you might fall into a pit never to emerge again. As a palliative care specialist, I am there to show that the earth is still firm, and while the flowers may not bloom quite as you had once imagined, there is still grace just being in the garden.
Leah Couture is a palliative care physician.