Overcoming obstacles in and at end of life

August 25, 2011

A physician learns that a seemingly bad outcome or experience can be dignified if you take the steps to look past it and keep moving forward.

"I suppose," I responded with a sort of rote, detached courtesy as I thought about all that I had to do that morning. I had two interns to supervise, 16 patients to know about as surely as I did the back of my own hand, I had to brush up on the ins and outs of myocarditis to answer the questions that were undoubtedly going to fly my way during the noon-time conference, and sign off on a 2-yard-high stack of charts in the medical records department.

"No, doc! Please, don't just guess, think about it," he said, pleading as much as instructing. "Empty's how I feel right now as my body settles the score for all the [things] I've done to it. Without my say-so, it's marching in the wrong direction, leaving a shell of a guy behind. I need you to understand that if we're going to go through this thing together."

Yet there I was, being lifted out of my familiar furrow by someone who knew better than I what remedy was needed most-understanding that solace could stem from an appreciated stillness between two unlikely comrades only if that calm was later broken by the noise of deep understanding.

At that moment, with that patient, silence was what mattered most. But there it was, 8:56 a.m., 4 minutes away from reporting to rounds with my team, and all I allowed myself to hear was the march of those 240 seconds ticking like thunder in my head.

Mechanically, I moved on to the different, albeit familiar, matters of the day. Throughout the morning, however, I couldn't help but question whether doing so had created the impression that I held cheap his concerns. I did not. I just hadn't become as adept as I'd liked at allowing my heart to be an apprentice to the grief and loss inherent in illness-whether one has it, witnesses it, or cares for it. Jack was going to change all of that by educating my heart, and we had just begun course 101.

FACING BATTLES

At the time, Pallie, as his friends and family called him, was a proud 71-year-old World War II veteran. I soon discovered he was an Army man who had stormed Omaha Beach in June of 1944. He was one of those boys of summer who had more courage than many in the generations that would follow his, but he wasn't loud about his performance during that momentous time in history. For him, it was a "duty," and as such, his work was to be done with humility, integrity, and rapacious effort.

Pallie didn't need to wax nostalgic with me or anyone who asked about his service, and he didn't need or want a tribute. He only needed to be decorated with my appreciation of his present circumstance and perhaps an awareness of the battles he went through, including the one he was now facing. I'm afraid that I offered neither response on that particular morning, but I was learning.

Perhaps because of what he experienced during his Omaha Beach days, or while crossing Europe with his unit, he became a big fan of the bottle. He was a scotch drinker for the most part, but he certainly didn't refuse a swig from any other bottle during the 50-odd years since his discharge.

Consequently, he had liver cirrhosis and his condition was moribund when I met him. As a medical team, we had addressed his jaundice and his ascites (detaining them a bit at least), but he was now beginning to enter the fatal stages of the disease. His blood was no longer clotting efficiently and his kidney numbers were way off. We knew that it was only a matter of time before either hepatorenal syndrome took control, or coma and brain swelling, or perhaps both. In any event, it was clear that Jack wasn't going to sleep in any other bed outside of the Veterans Affairs hospital before his death.