Monday, April 27, 2009

Francisco Goya

Francisco Goya (1746-1828) was one of Spain's greatest artists and his works have become a chronicle of Spanish history. By painting the aristocrats' idyllic lives in portraits, his paintings serve as a visual account of this important time in Spain's past.

In 1792 however, at the height of his career, Goya contracted cholera with subsequent sequelae of paralysis, partial blindness, vertigo, tinnitus and eventual deafness. Gone were his colorful happy portraits, and what followed were new dark and macabre paintings.

We can get a glimpse, possibly, into his psyche with his etching "?De que mal morira?" ("Of what illness will he die?") (1796-97). The physician depicted as a donkey in a suit may be how Goya viewed the medical community at the time. In the background we see the hooded figures waiting for this gentleman's death, while the physician can do nothing but take the man's pulse.

Although Goya survived his illness, he was left permanently altered. Many believe he suffered an encephalopathy of sorts from the high fevers during his earlier illness causing a degree of madness. Most indicative of this dark period are the "Black Paintings", done at the age of 74, they are a series of 14 works done in fresco style on the walls of his house.

The very method of painting on your own walls, implies a privateness to the pictures. They weren't painted to be viewed by anyone but the artist himself, as a kind of visual diary to the thoughts and images he was experiencing in his older age.

In this series is "Two Old People Eating"(1820), these 2 men both pointing at who knows what, could have been Goya's only companions for his meals. The figure on the right is almost skeletal, and both seem to be taunting the artist.

These next two pictures in the Black Paintings collection framed one of the doors downstairs, with "Two Old Men"(1820) on the left and "A Manola"(1820) on the right. Here we see the possibility of Goya as an old man with the call of death being whispered in his ear. Whereas in the next scene the manola is in mourning clothes, resting on a grave- maybe Goya's? It says much to know Goya painted these on a doorway to which he was forever walking through. Perhaps reminding himself daily of his own mortality.

Providing yet another glimpse into his world, Goya left us with "Self-portrait with Dr. Arrietta" (1820). Once again a commentary on the physician-patient relationship, this time the doctor offers compassion with his embrace and cup of kindness to the artist himself. The haunting figures are still present, but the doctor acts as a barrier of protection. The painting is inscribed on the bottom with "Goya in gratitude to his friend Arrieta for the skill and care with which he saved his life in his acute and dangerous illness suffered..."

Illness abruptly changed the nature of Goya's paintings, just as terminal illness changes the reality of our patients' lives. What images would we see depicted if our patients' narratives could be portrayed, like Goya, in works of art?

For a look at more Goya paintings see the Black Paintings and a large collection at Olga's Gallery.

Monday, April 27, 2009 by Amy Clarkson · 1

Monday, April 20, 2009

Until It Sleeps

CLEVELAND - APRIL 04:  (L to R) Jason Newsted,...Image by Getty Images via Daylife

Metallica has been in the press a lot lately. They were inducted into the Rock and Roll Hall of Fame on April 4th. Also, this Spring, Guitar Hero Metallica was released. We tend to post more on the music genres we are familiar with, but with all this attention, I'm going to delve into the world of thrash metal. Really, I just wanted to add "Metal" to our label cloud.

So what does a thrash metal ("an extreme subgenre of heavy metal that is characterized by its fast tempo and aggression") band have to do with palliative care? It was recently pointed out to me (by my husband) that Metallica's lyrics are often based on their life experiences. In fact, Metallica vocalist James Hetfield once said "All our songs deal with my youth in various ways." "Until it Sleeps" was written by Hetfield and Metallica drummer, Lars Ulrich based on Hetfield's experiences and losses.

Hetfield was raised as a Christian Scientist. When he was 16, his mother (a devout Christian Scientist who is said to not have believed in or sought traditional medical treatments) died from cancer. Her death is also said to have been the inspiration behind the songs "The God That Failed" and "Leper Messiah" (obviously a recurring theme!). Many years later, his father also died from cancer. Per music lore, Until It Sleeps was written about cancer.

The song starts " Where do I take this pain of mine, I run but it stays right by my side". He goes on to describe something inside that "grips", "stains", "hates". Something that needs to be torn out and washed away. At first, I interpreted this as being the cancer. But could it be the pain and loss caused by the cancer? Sort of a way of showing the similarities between the two (the physical form of the cancer eating away at the body and the emotional pain eating away at soul). Why does he say "And the hate still shames me"?

The video is inspired by the Renaissance painting, The Garden of Earthly Delights, (particularly the third panel of the painting representing hell) by Hieronymus Bosch (Wikipedia link has a great close up of the painting when you click on it) and other works of art that depict the fall of man. There is a lot of religious imagery which could represent some of Hetfield's own struggles with religion. A word of warning: This is a heavy metal video and some of the imagery is disturbing. These images do not represent the views or opinions of Pallimed or any of it's writers. Note prominent the fall-of-man themes throughout.

Where do I take this pain of mine
I run but it stays right by my side
So tear me open and pour me out
There's things inside that scream and shout
And the pain still hates me
So hold me until it sleeps
Just like the curse, just like the stray
You feed it once and now it stays
Now it stays
So tear me open but beware
There's things inside without a care
And the dirt still stains me
So wash me until I'm clean
It grips you so hold me
It stains you so hold me
It hates you so hold me
It holds you so hold me
Until it sleeps
So tell me why you've chosen me
Don't want your grip, don't want your greed
Don't want it

I'll tear me open make you gone
No more can you hurt anyone
And the fear still shakes me
So hold me, until it sleeps
It grips you so hold me
It stains you so hold me
It hates you so hold me
It holds you, holds you, holds you until it sleeps
So tear me open but beware
There's things inside without a care
And the dirt still stains me
So wash me 'til I'm clean
I'll tear me open make you gone
No longer will you hurt anyone
And the hate still SHAMES me
So hold me until it sleeps
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Monday, April 20, 2009 by Amber Wollesen, MD · 4

Monday, April 13, 2009

Franz Schubert "Death and the Maiden"

Franz Schubert was a gifted composer who died tragically young. Easily considered among the "greats" of composers, Schubert contracted syphilis in 1822 at the age of 25. He continued to compose, even as his health deteriorated. Many say that the works of his last 2 years became very dark, showing a deeper sense of spiritual awareness, and even a sense of the "beyond".

At the age of 20, Schubert put to music a poem by Matthias Claudius entitled "Death and the Maiden". The lied portrays a maiden begging for death to pass her by, and Death trying to persuade. The words from his song and Claudius's poem are as follows:

Stay away! Oh, stay away!
Go, fierce Death!
I am still young, please go!
And do not touch me.

Give me your hand, you beautiful and tender vision!
I am a friend, and come not to hurt you.
Be of good cheer! I am not cruel,
You will sleep softly in my arms!

This theme of Death and the Maiden is seen in art as well as music. Usually death is portrayed seducing or tempting a beautiful maiden. The idea that death would be a temptation began earlier in the 1400's when death was portrayed in the Dance Macbre, playing an instrument, luring people to death. Perhaps if Death was a temptation, then humankind could avoid the temptation, and avoid death? Death and the Maiden as a theme also conjures up a feeling of vulnerability in youth, as well as beauty. It leaves us with the feeling that life is fleeting, as beauty can be.

Schubert did an interesting thing. In 1824, a few years after his syphilis diagnosis, as his own mortality became central to himself, he re-worked his original Death and the Maiden lied into a string quartet. The theme, while similar to the original lied, takes on a very agonized and at times urgent tone. We might surmise the urgency he himself felt as he became more ill.

Listen first to the earlier lied by Schubert. This video from YouTube of Marian Anderson singing has a classic Death and the Maiden art image shown in the middle. (For email readers click on the post's title for re-direction to the original to see the video)

Second, here are two short videos I've done from the later string quartet. You'll notice the words from the original lied placed in the video, as well as suggestions to what you're hearing. The first is the maiden and the second Death answering. Hopefully you'll appreciate the dramatic difference in the earlier lied and later quartet and notice that the theme of "Death and the Maiden" took a very personal turn for Schubert.

A few short years later Schubert did die. He was only 31. It is believed he died from complications for syphilis, though some believe he may have died from mercury poisoning, which at the time was the standard treatment for syphilis.

Monday, April 13, 2009 by Amy Clarkson · 2

Monday, April 6, 2009

Goodbye ER

ER premiered Sept 19, 1994 and was the creation of the late Michael Crichton. (Crichton wrote the screenplay for ER based on his experiences as a resident.) On Thursday, April 2nd, after a 15 year run, the series finale aired on NBC, entitled "And in the End..."

I haven't watched ER in many years. I stopped watching shortly after I started medical school because I just couldn't take the medical drama anymore. But I just couldn't help myself from tuning into the finale. When I watched ER in the past, it was not from the perspective of a palliative care doctor. I was pleasantly surprised Thursday to find several palliative care themed plot lines.

First off, one of the main plot lines was actually based on a true story. Executive producer, John Wells, 17 year old niece died from alcohol poisoning in December. This plot line, in which a teenager is brought in after a night of binge drinking, was written to raise awareness about this issue.

Another case involved a gentleman with AIDS brought in for breathing difficulties. After a workup, he is diagnosed with cancer. When the resident brings up chemotherapy to buy him a few more months, the patient refuses saying that for years now he has just been living for all of his friends who have died from AIDS. "I've been trying to live for them, you know, keep their memories alive. But I've had my time. No regrets." He goes on to describe an experience skydiving and hopes that death feels the same.

Resident: Is there anything I can do for you?
Patient: Yeah, there is. I don't want it to hurt.
Resident: We can help with that.

But to me, the most impressive story was that of an elderly MS patient admitted with pulmonary edema and sepsis. (Sorry, I couldn't find a good clip of this. But the full episode can be legally watched on the NBC website here.) The doctor explains to the husband that they can give his wife IV fluids but it will only do more damage to her lungs. When her husband wants more aggressive things done, the doctor explains that even with aggressive treatments her life will only be prolonged by a week or two (He prognosticates while having a goals of care conversation! Is this the first time that has been seen on TV?) and these things will just prolong her pain and suffering. He then says "It's time to talk about how to make her as comfortable as possible." Later in the episode, the husband is upset that his wife has an apneic episode. The nurse explains that irregular breathing is a normal part of the dying process.

That's quite a bit of palliative content for one episode (even a 2 hour episode). Maybe someone who watches regularly could tell me if this has been the norm. I think that death is commonly dealt with on ER but what I find interesting in this episode is how it is dealt with more as a natural part of life, not always a struggle. Comfort is actually brought up in both of the last two story lines I mentioned. So, farewell ER! While I haven't been a devoted follower, I am a fan of this episode.

Monday, April 6, 2009 by Amber Wollesen, MD · 6