I am in the privileged and humbling position of hearing the stories of patients’ pasts. Sometimes the stories are so horrendous that it takes all my energy to stop myself from crying as they recount the brutality of their experiences. I have heard harrowing descriptions of all manner of abuse done to patients when they were children. The abuse was perpetrated by peers and parents, siblings and health care providers. The stories are similar and yet different and each one shakes me to the core as a nurse, a mother, and a woman. I cannot imagine willingly and deliberately hurting another human being, much less someone I am supposed to love and protect. Of course abuse happens to adults too, but there is a qualitative difference between harming those who are young and defenseless and adults who at the very least understand what is being done to them.
There seems to be no end to the awful ways in which one person, often an authority figure, can hurt a child. Patients have told me about sexual abuse in the bathroom of their elementary school committed by an older child, at times witnessed by others who did nothing to stop what was happening. They have told me about nurses who manipulated their genitals in the dark of night under the guise of providing care. I have sat silent and listened in horror as a patient recounted what their brother or father or uncle did to them with family members in the next room and how they suffered in silence, fearing what would happen if they told.
They carry these secrets into the rest of their life, and for some it is only when cancer happens that the memories resurface. For one man it was lying alone on the table in a darkened room during a radiation treatment that caused him to experience the visceral fear of being abandoned. It may be the feelings that come rushing back with invasive examinations or treatments for cancers involving genitalia or breasts that take the patient back to similar experiences in their past when they didn’t even really know what was happening to them. Men have recounted to me the revisited trauma of violent rectal penetration after having a prostate biopsy and despite screaming to the urologist to stop, the procedure continued.
I maintain my professional demeanor in these interactions. When appropriate I extend a hand gently to touch an arm or knee. I sit in silence and listen. My face likely shows how sad and/or distressed I feel and I fight to not let my tears come. I do not believe that crying in front of a patient is a good thing. I don’t want them to have to comfort me; this is a normal human response and I don’t believe this is constructive in a therapeutic relationship. Others would argue with me that it shows compassion but I think that there are other ways to do that. So I have bitten the inside of my cheek on occasion and shed my tears when the patient has left.
Our patients bring the context of their lives into the hospitals and cancer centers where they receive care. Patient-centered care means that we need to take into consideration those contexts and, more than that, treat each patient as unique and deserving of the care that they want, not necessarily what we can offer. While our patients have every right to keep their secrets and their past from us, it is helpful to know about a history of trauma so that we can address situations that may be triggers for them or cause them emotional harm. I would like to know that my colleagues in radiation would adjust the lights in the room for the patient who feels afraid when lying in the dark. I would hope that the gyne-oncologist would work with the woman who needs internal examinations to mitigate the trauma that she relives at follow-up appointments. And I would insist that a man who was terrified and traumatized by a prostate biopsy would be offered anesthesia if he needed another biopsy, not to mention that the procedure would stop immediately if he wanted that.
I am not a specialist in trauma counseling and I offer a referral to an expert; only once has a patient agreed to this. Most seemed to have managed to deal with their past in one way or another, with or without professional help. Or they have buried the memories so deep that it is only in the experience of cancer that the trauma come flooding back. I am not sure if the rest of the treatment team knows about the pasts of the patients we care for. This is harrowing stuff to talk about or hear and our patients may not want to share with everyone or anyone. But when they disclose to me, I am honored by their trust.