The last lesson: Physician writing contest honorable mention

I knew there was something wrong when I visited her at her home. I had known her for a long time, and she was in reasonably good health, except for moderate dementia, for a woman of 91, soon to be 92. Normally she would have done anything to stay away from the hospital, but she looked pale, felt weak, and had been having some blood in her stools. 

When I told her I thought she needed to come to the hospital, she paused a moment, looked at me and whispered, “Okay…okay.” 

That was Friday. By noon Saturday, she felt better after two units of blood and looked more like the woman I knew. The CT scan that morning confirmed what I suspected, a malignancy, but not in the intestine.

Rather, a tumor of the pancreas was present with evidence of metastasis-a death knell for a patient of 91.

The slow, contemplative walk

Those of us who care for patients are all too familiar with that walk down the hall to a patient’s room to give him or her bad news. We know that in the span of a few minutes we will significantly and irrevocably change the course of that person’s life. It is a slow, contemplative walk, almost like a walk down death row as in some cases, we are delivering just that.

She had just finished breakfast; her husband was visiting her. After a cheery, “Good morning,” and exchange of the usual pleasantries, I sat on the edge of her bed and tenderly held her hand as I conveyed the bad news. I’m not sure exactly how I expected her to react-tears, sorrow, anger?

Instead she looked at her husband of 67 years, then at me and with a tone of resignation, and perhaps relief, said, “Well…I’ve lived a long life and I’m ready to die.”

She had been trying to hold her dementia at bay by looking at familiar pictures and playing endless games of 5-card stud poker on her iPad. Her husband had begun writing everything down on a notepad in the kitchen, but even then she asked the same questions over and over.

Her 89-year-old sister and life-long best friend came to live with them to provide the additional care that her 92-year-old husband would find difficult. Between the two of them, she was never alone.

What I thought would be two to four weeks stretched to nine weeks. This additional time, an unexpected blessing, provided opportunity for her to visit with all her family, attend birthday parties for two of her great grandchildren, and hear the things her family needed to say about love, loss, gratitude, and the sorrow that would fill them when she was gone.

Medication and compassionate care from hospice kept her comfortable for the most part. I visited her often. In the evening before her passing, when she was taking a turn for the worse, I whispered in her husband’s ear that I thought she might have a very bad night and to call me. He called me at 2:20 in the morning to say that she “…was having a hard time dying.”

I’ve cared for dying patients before and had planned for this eventuality, arriving at their home with morphine and lorazepam in hand to help her comfortably transition from this world. I had promised all my terminal patients that they would not die in pain. Unfortunately, when I arrived a few minutes later, she had already passed.

HIPAA regulations would preclude me from mentioning her by name, but suffice it to say that I had known her all my life and I called her mom.

Trading comfort for longevity

It is said that dementia is the last of life’s great lessons in patience, love, kindness, and understanding that your parents give to you.

During that last nine weeks, I learned more about the value and importance of these to patients who are dying or demented than what my 35+ years in practice taught me. I learned the importance of sustained family contact, of open, loving, and caring conversation, of relieving pain and suffering, and of the value of the most important but perishable resource of all, time.

For my patients for whom a cure is not possible, I vow to them relief of pain and compassionate care. They don’t need to come to my office to see me; I’ll make a house call to see them. I work closely with the hospice nurses, aides, and chaplains as a team, and I give the families my cell phone number to call me with any questions and concerns at any time. (And by the way, patients and families have never abused this.)

As clinicians we all too often ameliorate our emotions by offering technology as a substitute for compassionate listening, complex surgical procedures in place of reason and understanding, and the hope of a healthy and endless life instead of the reality that all life is finite.

By failing to have discussions about the quality of life, we often spend countless hours in search of the elusive quantity-trading enjoyment for time, comfort for longevity.

Thanks, Mom, for this last most valuable and enduring lesson.

Roger Wujek, MDis a family physician in Litchfield, Illinois