At Day's End
This is a story of two deaths. That these patients' stories intersected on the same morning, in the same building, in two adjacent rooms, has left me thinking about them now that the day is almost done.
I was surprised to see Mrs. Stevens' name on my schedule today. She came to the office last week, and I felt sure that she'd be too weak for another visit. But I was glad she'd made it, as I've become quite fond of her.
She's seventy, and dying of metastatic lung cancer. She's a lifelong smoker, but at this point I'm not worried about cause and effect, accountability and responsibility. None of that changes what I must do now as her physician.
A recent PET scan shows that her lung cancer has spread to her skull and spine. She has only weeks to live. She knows this, because I've previously told her so.
At last week's visit, I asked what kind of care she wished to receive during her final months, weeks and hours.
"All that matters is that I make it until July," she answered. "That's when my grandson will come home for a visit. He's a soldier, stationed in Texas."
"Too far off," I said. Even as I spoke, I cringed at how blunt, even cold, it sounded. But I've known Mrs. Stevens a long time, and I believe that she appreciates my straight talk and knows that I care about her.
Delicately, I suggested that buried within the black cloak of her terminal illness was a small gift: the opportunity to spend her last few weeks with intention. Surrounded by family and friends, she would have the chance to say things she may not have thought to say out loud before. She'd have the time to see, feel and hear things in a way that the "living" often do not. She could wipe her thoughts clear of the clutter that infects our minds and causes pain and unhappiness. Just maybe, these last few weeks could be an incredibly special gift to her and her family--a chance to be more present than she'd ever been before.
That was last week. This week, I knew, hospice nurses were scheduled to make their first home visit. Now here she was in my office again, along with her daughter and grandson.
"I'm surprised to see you," I said.
"I thought it would be the last time I could make it, and I wanted to see you once more," she replied. "My family and I are going home to celebrate."
Her eyes sparkled. Despite her cachexia, bald head and baggy clothes, she glowed and radiated joy. I thanked her for sharing her life and death with me, and for the time that we'd had together. At the end of our visit, I hugged her goodbye, knowing it was my last chance to do so.
Routines being what they are, I moved right on into the next room. Here sat healthy, fifty-year-old Mrs. Drake, curled into a smaller version of her usual self and dabbing her eyes with a tissue.
"What's the matter?" I asked.
"My cat died last week," she sobbed.
Normally I'm not a pet person, and I often feel annoyed at the time and money that people lavish on their pets. But, with my reactions softened by my encounter with Mrs. Stevens, I stayed calm and asked Mrs. Drake to tell me about it.
"My cat died last week. I had her for three years, since she was a kitten. She was the only family I had," she said. "My kids don't speak to me, and the rest of my family is dead or uninvolved in my life. I know it seems stupid--it's only a cat. But I don't have anyone else!"
She went on to tell the story of how her children had stopped speaking to her. I suspected that her own mental-health issues had played a role in this, but as she described her children's drug and alcohol abuse, and their self-created messed-up lives, I could see how these too had helped to tear the family apart. She was truly alone, and painfully aware of it.
Her visit reminded me of how many lost souls I see every day--individuals living in a social isolation for which there is no medication. They come into my office, and I treat their respiratory infections, wounds, chronic diabetes and heart disease. I convince myself that I'm doing good, helping them with their ailments. But when they return home, they again face that oldest of human conditions, loneliness.
I felt moved by Mrs. Drake's story and her deep sadness. As I left, I bent down and gave her a hug. It was the only medicine I had for her.
"Perhaps you'll know when you're ready to get another pet?" I suggested.
"Yes," she replied flatly, but with a small smile on her lips.
Now, driving home, I weigh these two stories of death and loss. Their proximity was enough to crack open my routine and give me the space to reflect on what is precious in life to me and to those I care for.
Each story affected me differently. The first left me feeling hopeful and glad for my dying patient's choices and opportunity. The second left me full of despair and loss, not only for this patient, but for so many others.
As a family physician for more than thirty years, I know that it's quite possible to go to work, to move from room to room, to greet, treat and repeat my well-practiced routine and, at day's end, to leave feeling tired and numb, my sole thought being What's for dinner? I could give you many reasons why this happens, but that's not what this story is about. Or is it?
When a patient dies, we're often left feeling empty, with no easy way to share our sense of loss. But when I've emotionally engaged with a patient and his or her family, I'm no longer grieving alone. And when I've helped my patients to get the care they want, and they can die on their terms and not feel violated, I feel that I've truly been a good physician and a caring friend.
I used to feel uncomfortable caring for dying patients. Like so many in my profession, I hid behind my stethoscope and my professional title. Now I enjoy this part of my practice. I have a lot to learn, and it's not always comfortable, but it feels right and necessary. I now openly treat dying as a part of life. This isn't a novel idea, but helping people to die well isn't always valued in a profession that often views death as a sign of clinical failure.
With time and experience, I've learned that, for me, it's these small human interactions, not the momentous medical interventions, that make the greatest impact on my patients' lives and bring me the greatest joy in my practice.
A week later, Mrs. Stevens died at home, in the company of her grandson and daughter.
A month later, Mrs. Drake came to the office and told me about her new parakeet, Polly.
About the author:
Marc Tumerman has been a family physician practicing in Wisconsin for thirty-two years, the last eleven years with Mayo Clinic Health Systems, in leadership roles involving practice management and quality improvement. This is his second story for Pulse; he's also had pieces published in Scope (Southern Illinois University School of Medicine Literary Journal), Wisconsin Medical Journal and elsewhere. "Like many, I've chosen to write about some of my more meaningful patient relationships because it's these relationships that give meaning and fullness to my life. In addition, writing serves as a way to help me deal with some of the frustrations and limitations that life places on us at work and at home."