A patient's final "gift" moved me to tears

March 21, 2008

The captain's "gift" was something this internist would never have anticipated.

One of my favorite patients died at 9:20 one recent morning. I checked with the hospice nurse and noted the exact time because my patient would have wanted me to. It was an all-too-common cause of death-metastatic lung cancer-but he was an all-too-uncommon man.

I first met Captain Joe Small (not his real name) in August 2000, when he came in for a routine checkup. A 57-year-old commercial airline pilot with osteoarthritis of one hip, he had chosen me as his internist upon the recommendation of his kid sister, whose advice he seldom took. Tall and broad-shouldered, suntanned with aviator sunglasses, he looked the part of the classic airline pilot. I took an immediate liking to him, and was drawn in by his description of his career, flying wide-body 767s for a major airline after serving in the Air Force for eight years, including in Vietnam. He was the kind of pilot who could give one an unshakable faith in airline safety.

Captain Small seemed to appreciate my attention to detail and my policy of seeing patients on time. But one morning, while sitting in our waiting room with a 9 o'clock appointment, he glanced at his watch and barked to my receptionist, "It's oh-nine-oh-three-the plane is ready for takeoff. Where's the pilot?!" Years later, when he was in the throes of his illness, he referred to me as Captain Iglehart and I began calling him Doctor Small, for he had taken it upon himself to learn so much about his cancer and its treatment that I accused him of knowing more than I did. I also found myself using military time when I spoke with him.

Proudly bearing up under severe pain

Joe, feeling perfectly well, took the news with characteristic measure as he and I mapped out the game plan. The percutaneous biopsy showed non-small cell carcinoma; he had positive mediastinal lymph nodes. He underwent chemotherapy and radiation therapy without complaint. Subsequent brain metastases necessitated serial craniotomies. When I telephoned him the night before one of his surgeries, he said, "I'm to report at 1100 hours, and I expect to be in recovery by 1600 hours." I pitied the poor surgeon if he was running late.

With time, Joe's unresectable right cervical lymph nodes began to cause dysphagia and pain, and he reluctantly agreed to home hospice. He continued to resist help from even his sister, keeping her at arm's length but allowing her to speak with me about his condition. I kept in regular phone contact with him, often just leaving a voice message, "Paging Doctor Small, this is Captain Iglehart calling . . ."

Several days later, his sister called me to report that he had been admitted to inpatient hospice. One night, after my monthly nursing home rounds, I stopped by at "2200 hours" to see him. I first reviewed his chart, and was shocked to see that under his chief complaint on admission, the oncologist had written "PAIN!!" I had just spoken with Joe two days earlier, and he hadn't mentioned pain. How long had he been suffering? Had he been too proud to complain? Morphine had been ordered, and the dosage increased, but was it enough?

I hesitated at his doorway: silence. He was sleeping peacefully, his still-tanned face on a crisp white pillow. His right cervical metastasis was the size of an avocado, but thankfully had remained subcutaneous. I dared not disturb him, so I just held his hand and said, "Doctor Joe, it's Captain Idy."