Seeing With My Ears.

Therapeutic presence is one of the fundamental skills that palliative care providers have to offer. The COVID-19 pandemic has created many barriers to connection that impact the way providers practice. This narrative piece about a remote cross-country palliative care encounter offers reflections on creating therapeutic presence amidst the current pandemic.

There is a special type of moment we sometimes experience in medicine. Time seems to slow down, and the atmosphere shifts in the room with a patient or family. Protective layers are shed, and their deepest pain is allowed to surface without modesty. They are the moments when raw vulnerability feels safe enough to have a presence.

These moments are not easy to experience as a listener; we often feel the understandable instinct to get out to the other side by any means. As a palliative care physician and psychiatrist, however, I could spend a lifetime shouting from the rooftops about the importance of these moments. Rather than flee from the distress, I have challenged myself time and again to sit with these moments, witness these moments, and nurture these moments. They are fundamental to what we do. Helping to hold suffering in its most vulnerable state is at the core of being therapeutic.

I recently found myself in one of these moments, although under the most unexpected of circumstances. During the height of the first wave COVID-19 crisis in New York City, I became emergency credentialed to volunteer remote palliative care services from California. My first consult was an older gentleman who had been intubated for quite some time. His prognosis was grim. I was asked to speak with the family—who were restricted from physically seeing the patient or care team—to help them understand the prognosis and readdress goals of care. So the patient's daughter found herself on the phone in New York, talking to a doctor in California, discussing a man that I had never met and that she had not laid eyes on since he first walked through the hospital front doors.

As the discussion started, however, I began the journey of becoming acquainted with this man, not just as a coronavirus disease patient, but as the heartbeat of a large multigenerational family. His daughter described his green thumb and his tendency to laugh the loudest at his own jokes. She told me of the silly face he makes to get the biggest smiles out of his 18-month granddaughter. She shared amazing experiences that he had survived while growing up abroad and lessons he relentlessly instilled in his children when they were young. She continued to share small pieces about him until the weight of how remarkably beloved he was became undeniable; with it came the weight of how unthinkable it would be to lose him.

This is how, despite 3000 miles between us, we found ourselves in one of those moments of deep vulnerability. It greeted me like a familiar old friend I have grown to know well over the years, and I replied to it—as I always do—with a welcoming embrace. My body relaxed as my shoulders dropped comfortably. I let out a deep breath that gently spoke to the pain for me: I am here, and I'm not going anywhere. You are safe to come and be seen right now. I let the muscles of my face fall into the familiar expression that whispers: I see you … and I care. I then drew on the most powerful tool I have to offer: silence. Silence paired with presence.

I was suddenly jarred out of the deeply familiar. Looking at the phone in my hand, the realization came: She can't see my face. She can't hear or see the cadence of my breath. She does not even know that I'm sitting, let alone how I'm sitting. Without my physical presence, how would she interpret my most tried and true tool: silence? For the first time in what had been a very long call, I felt acutely aware of that which I could not see: her expression, her position, her eyes. My read of a room is usually sharpest in these moments of silence, and yet now I felt blind. The vulnerability had certainly come, but had I done my job in inviting it to stay present with us?

And then I heard the heartbreaking gasp: a small noise that let me know that over the phone and across all these miles, tears felt comfortable enough to fall. The pain had not put its armor back on; it remained present. My heart sank with the depth of her suffering while my gratitude rose with the honor of being trusted to hold it with her.

As all but one of our senses could not be accessed, I drew on words. Her tears, the weight of which traveled heavily across the airwaves, filled the space, while my sparse comments wove a nest to catch those tears as they dropped. “I'm so sorry this is happening … I can feel how deeply loved he is … I'm right here with you …” Through it all, I remained sitting down; I maintained slow, deep breaths; the genuine empathy never left my facial expression (albeit unseen). I trusted that the nurturing nonverbal communication I have grown to rely on over the years would guide the words coming out of my mouth—their volume, their speed. Somehow my body instinctively knew how frequently to intersperse these comments amidst the sounds of her distress. It was the feel of my words, of my presence, that would weave a nest soft enough, yet secure enough, to hold vulnerability.

The moment—which was of course far longer than a moment—came to an end. Having been seen, held, and honored, her deep suffering was placed back in its protective armor. We shared a slow breath, and the conversation naturally shifted forward.

Therapeutic presence is one of the fundamental skills that palliative care providers offer to patients, families, and colleagues. During this unprecedented time, the need for our therapeutic presence is at its greatest, while our ability to be physically present for encounters is deeply challenged. In this interaction, so similar to those I have experienced countless times in palliative care and yet also so incredibly different, I was reminded of a very important lesson about human connection: that we can touch with words, that we can hold with silence, that we can speak with breath, that we can see through sounds.