Dr. Lauren Michalakes offers a warm handshake and gentle smile to visitors at Gosnell Memorial House in Scarborough.
As medical director at the 18-bed hospice house, Michalakes’ job is to control pain and manage symptoms of terminally ill patients.
Unlike the traditional approach of medical doctors, her goal is not to rehabilitate or cure patients. It is to help them through the dying process.
“I am there to relieve suffering,” said Michalakes. “That is my primary role.”
Michalakes is part of a hospice team that also includes a nurse, home health aide, social worker, volunteer and chaplain. The team coordinates care with each patient and the patient’s loved ones.
Michalakes assumed her post as medical director when the hospice house opened Aug. 1. But she has devoted a large part of her medical career to providing end-of-life care, previously working at a hospice in western New York.
Michalakes, 50, is married to an emergency room doctor. They have three children. She commutes from Camden to the Scarborough hospice house, but expects to move to southern Maine after her 17-year-old daughter graduates from high school next year.
She talked with the Current about her new role at Gosnell Memorial Hospice House and the hospice philosophy of letting patients and their families determine end-of-life care.
Q. What is the role of a medical doctor at hospice?
A. The physician doesn’t drive this care. Dying is not a medical event. I’m not in charge. The patient is in charge.
Most health care is defined and determined by the disease and the interventions. It is a very biomedical model, as opposed to the hospice model.
People are multidimensional. They have physical, emotional and spiritual needs. The dying process is much more complex than getting a hip fixed or bypass surgery. It is much more humanly complex.
If you look back at how people used to die 100 years ago, it was at home, surrounded by family. Over the course of time, we have learned we can treat diseases. As we have made that transition, dying has become part of hospital culture.
Dying people are taken away from their families and the environment where they feel most comfortable. Through hospice, we’re trying to bring (the dying process) back home where it all started.
Q. How is the patient in charge of care?
A. When the doctor comes in, there’s an expectation by the patient that he will be poked and prodded and the doctor will do a patient history. I do a little bit of that. But a lot of my interventions are the minimum to satisfy my responsibility.
The patient may not need a full history or physical. Or a patient may say, “Please don’t examine me anymore.” I have to assess how the patient feels. I let him tell me what he needs.
In hospitals, there are rules for exams, rules on when to have medication. Whatever the hospital regiment is the patients need to follow. Those rules are important to meet the demands of the hospital. But we don’t require it here. We don’t have those expectations. We are there to meet the patient’s end-of-life needs.
Q. How do terminally ill patients come to terms with dying?
A. People sometimes retreat to a lonely place within themselves when they know they are dying. Frankly, it is difficult to imagine what this must feel like. We who do end-of-life care describe it as “existential distress.”
There is the knowledge that one day the world will exist without them. They think: “I am leaving my family. How will they survive? Where am I going? What has my life meant?”
Dying people often look for meaning. They try to figure out their beliefs in an afterlife. They look back at their whole life’s work.
The patient may have been proud and self-sufficient and used to caring for others. Now that person has to turn around and be a patient.
All this takes a lot of emotional work, and there are so many opportunities for stress on the patient and care giver.
Q. How does the hospice house help patients and families through the dying process?
A. When a patient comes in to the hospice house, he is cared for by a medical team but is still in a homelike setting. Family members can go back to their previous roles of being a family and not a glorified nurse or home health aide.
This is a tremendous gift of relief. They can just be, and wipe the slate clean.
You often find families so regimented to providing care they lose track of what is happening before them, that a loved one is dying. They are so busy with medication and food and worry. They don’t stop to realize this is an important moment. At the hospice house, we lift some of that burden. We give them the ability to spend time together and just be in the moment.
Q. Is it hard as a hospice-based physician not to focus on curing a disease or condition?
A. My role is to relieve suffering. This type of medicine is the most pure form of medicine there is. Through technology and interventions, traditional medicine has lost touch with a primary mission – to make people feel better, to provide comfort.
My role is to find a way through my skills to make the patient comfortable. I set the stage so the patient can do the work of dying in the emotional and spiritual domain. If there is pain and nausea and shortness of breath, the patient cannot say goodbye or open his mind to life after death, if that is what he believes. Making peace is part of the dying process.
Q. How did you first get involved in hospice work and end-of-life care?
A. Luck led me to this practice. I had the opportunity to work in a large hospice in western New York and I never looked back. That was 12 years ago.
I was a little bit anxious at the time wondering if I would miss the complexities of medical problem solving. But then I started working with families and staff. I realized the opportunities to feel rewarded by the nature of this work far exceeded what I got out of working in a general medical practice.
Q. How did you wind up in Maine from New York?
A. My husband is a physician. I had my third baby late in life. I took a sabbatical, and we made the decision to move to Maine for family reasons. We ended up in Camden. I thought I would just go back and be a doctor (in general practice). Then a career opportunity arose (at the hospice house) for expertise in end-of-life care. I fell in love with the mission and vision.
Q. What do you enjoy most about your work?
A. It is probably fair to say that most people do hospice and end-of-life care because we like to help people, because we enjoy the opportunities to make a difference.
On a personal level, there is no other opportunity to learn, to really experience things that are as important in life.
I learn something from every single patient I take care of. The human condition is so strong and powerful. I have the opportunity to see things I don’t see elsewhere in medicine.
I enjoy watching the growth and changes in people during this time of life. These are the most important moments people spend together.
I live a better life for taking care of patients. I just hope when my time comes, I can die with grace and dignity and compassion.
Dr. Lauren Michalakes describes the feeling people have at the end of their life as
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