A patient suffers endlessly with guilt about her long-ago smoking. She needs to let it go, but can't. Another patient keeps riding his motorcycle despite low platelets. He needs to let it go for now, but won't. What's going on with patients who can't or won't let something go?
An image from my childhood comes to mind: I was halfway across the playground's horizontal monkey bars. I couldn't just keep hanging. But I couldn't loosen my grip.
"Letting it go" has a variety of meanings. Here I mean: choosing to stop owning or stop being concerned about "it"-whether "it" is a problem, injustice, opportunity, role, relationship, emotion, or material thing.
Ultimately, letting it go is an act of empowerment. Doing so relieves (or prevents) suffering and frees energy for more important or pleasurable things. If "it" is not important, we effortlessly let it go. Like after a penny slips down a storm drain.
If "it" matters, letting it go becomes a more challenging process. It begins with a calculation that the pros outweigh the cons. Then, accepting that life involves loss, we decide to let it go. Or believing that being happy (or professional or productive) trumps being right, we let it go. We may cry or curse, but we move on.
Now let's consider a few examples of what "it" is for patients who need to let it go:
* Guilt about their role in their health crisis;
* A missed diagnosis that worsened their prognosis;
* Strangers staring at their compression sleeve or electrolarynx;
* A friend's abandonment; a loved one's insensitive comment;
* A routine pleasure (visiting grandchildren; gardening);
* A long-anticipated trip or event they have to miss;
* Involvement in a meaningful activity-in-progress (project; career);
* Problems/failures that occur after other people take over their task(s);
Each scenario naturally causes patients to experience some mix of grief, anger, or other unpleasant feelings. Letting it go should provide relief from their distress. They should feel new energy to move on. Right?
Well, maybe that's the problem. Maybe patients don't feel empowered by their act of empowerment. That could happen if a natural flare of new negative thoughts and feelings eclipses any sense of relief or moving forward.
For patients, a penny slipping down a storm drain may elicit profound sadness, great anger, or even loss of sense of self. Because patients' dilemmas don't arise in a vacuum, but in a vortex of unwanted change and loss.
Soon after my diagnosis, my husband handled a minor issue with the kids. I let it go, secretly wishing he'd handled it differently. Mine was a wise move. An empowering act. Yet here's the thing: Letting it go stirred grief and frustration-not at my husband but at my situation. I felt powerless.
Not uncommonly, issues of control play into patients' emotions. Well-meaning friends and family often suggest, "Just let it go" or insist, "You have to let it go." For some patients who are feeling a sense of loss of control, such sage advice may push their button. Either unconsciously or by choice, they tighten their grip around the hope or grudge or activity that's causing their suffering.
In addition, the inherent uncertainty of a prognosis can confound patients' calculation. In particular, patients may fear misjudging and letting it go too soon.
For years I struggled with my decision to stop practicing medicine, even after patient care became impossible. I blame all the stories and images that trumpeted ordinary people doing extraordinary things after their cancer diagnosis. While inspiring me in life-affirming ways, that magnificent ethos of triumphant survivorship also burdened me. Even today, each time I want to do something but choose to let it go because of energy limitations, self-doubt creeps in. Am I weak? Lazy? Giving up too easily?
Clinicians play a crucial role in helping patients let it go in healthy ways. Help begins with providing the information patients need to make their calculation: expert assessment of their condition and prognosis; correction of misperceptions and erroneous information; diagnosis and treatment of organic pathology (depression, dementia, pain, fatigue) that might impair their judgment about-or ability to-let it go.
To guide patients' efforts to choose wisely, clinicians can...
* Clarify the mission: "The goal is to determine the best path for you now."
* Advocate for autonomy: "This is your choice. You can let it go-or not."
* Mention bias: "The media doesn't promote stories of people who got sicker or died because they kept pushing and hoping, nor of those who regret holding on, their hopes unfulfilled."
* Reframe: "Letting it go is taking charge. It frees you to move forward."
To support patients' efforts to let it go, clinicians can....
* Reassure patients: "Letting it go is not giving up or giving in."
* Acknowledge challenges: "Letting it go takes courage and strength."
* Emphasize control: "Letting it go is an act of empowerment, even if it doesn't feel like one at first."
* Provide advice:
* "Look forward. Focus on how letting it go will make your life better."
* "Find distractions and accept support through the adjustment period."
* "Grieve, as needed. Even if a loss is permanent, the grief is temporary and healing." (Seemy "Honoring Grief" Patient Handout in the8/25/14 issue)
At times in life, letting it go is the best thing to do. Decades ago on the playground, I finally released my back hand. The drop of momentum empowered me to swing forward and grab a bar closer to my destination.
Ultimately, letting it go is an act of empowerment. By helping patients overcome the obstacles, you empower them to get good care and live as fully as possible today, tomorrow, and every day.