"It's time to quit"

In a final act of compassion, the author gave his patient the signal he'd been waiting for.

By Matthew L. Davis, MD
Family Physician/Long Beach, CA

Last week, I lost an old friend—that's old as in age, not longevity of relationship. Mr. Bird, as I'll call him, was 78 and had been my patient for only six months, but we had a special bond from the beginning.

I'm lucky to be able to get close to many of my patients. That connection is partly inherent in family practice, and partly due to my personality and ability to take a good social history. Even when I'm running behind schedule and a patient wonders aloud why I need so much background information, I'll explain that, in this age of fragmented health care administered by a variety of specialists, it's crucial that I know my patients well.

Mr. Bird could tell I had bad news when he came for his second office visit. A year earlier, his wife had died from lung cancer. He knew the world of disease, and the agony and anguish that came with it. Now Mr. Bird's chest X-ray confirmed our fears; he, too, had lung cancer.

"Let's do what we have to do," said Mr. Bird stoically. "But, Doc, I'm counting on you to tell me when it's time to quit. My father was part Indian, and he always said, 'When it's your time, go out to the wilderness, sit under a tree, and let nature take you.' " Mr. Bird visualized a tree. I visualized administering the last few milligrams of morphine and turning off a ventilator.

In the months that followed, Mr. Bird endured scans, biopsies, radiation therapy, and multiple hospitalizations for COPD exacerbations, CHF, pneumonitis. Throughout, he always treated me with kindness and respect, allowed me to take care of him, and thanked me for even my smallest efforts.

And because Mr. Bird wasn't a managed care patient, I was the admitting physician and primary doctor during all of his hospital stays. (I'm required to turn over inpatient care of HMO patients to a hospitalist.) So we developed an old-fashioned doctor-patient relationship. We'd talk about his desire to drive up the California coast in his RV "just one more time," and his family's plan to scatter his and his wife's ashes in the Pacific. Nurses and his own daughter saw him as cranky and miserable, but I told his daughter that he was the kind of patient who made being a doctor a joy. She gave me a thanks-for-trying-to-be-nice look and said, "You've got to be kidding."

During Mr. Bird's last hospitalization, he was assigned to the dreaded four-bed room. There, amid the bustling care of other patients and the 1940s decor, I knew it was time to tell him. Two days before, I had talked to him again about hospice care so he could die at home, where he wanted to be. But despite his earlier acceptance of his terminal illness, he had backtracked to the denial phase and said he still wanted to fight. And I had even tried to convince myself that there was still time for him to hire a companion to drive his RV up the coast.

But this was the second time in 14 days that he had to be admitted for respiratory distress, and I knew the steroids and bronchodilators weren't going to be effective. I no longer saw a survivor, but rather the agony of the terminally ill. Through the noise of the ward, the hiss of the oxygen, the beep of the equipment, I said, "It's time to quit." With a crooked smile, Mr. Bird replied, "Doc, make the arrangements and get me home." Thirty-six hours later, Mr. Bird died.

I never had a chance to say a final goodbye to Mr. Bird. Soon after he died, I wrote a newspaper editorial about how frustrated I was with fragmented health care and hospitalists taking over the role of the traditional full-service family physician. I thought about Mr. Bird as I argued for continuity of care above other managed care priorities. I hope Mr. Bird realized that because I knew him and cared about him as a person—not just as a patient—I advocated for him at every turn and was right beside him as we fought the good fight. Perhaps that tribute to Mr. Bird—indeed, the joy of being his doctor—is the most fitting goodbye.

 

Matthew Davis. "It's time to quit". Medical Economics 2001;18:89.