Sometimes we do things right

By giving a dying patient the gift of time, this doctor learned the value of compassion.

By Kenneth Pickover, MD
Internist/Staten Island, NY

Whenever I feel overwhelmed by the hectic pace and hassles of medical practice, I recall an elderly patient named Harry, who came into my life 10 years ago.

Harry Fineman (not his real name) was the nicest of patients: never demanding, always more interested in hearing my problems than telling me his. He was stocky, with thick white hair, blue eyes, and a ruddy complexion. He had a ready smile and always looked as if he didn't have a care in the world.

Harry often came in with his wife, Helen. They were one of those couples that blended together seamlessly. They were my ideal of domestic tranquility.

Harry and Helen were snowbirds: they lived up North during the spring and summer, and spent the winter months in Florida. That's why I saw Harry frequently in the warmer months. His glucose and blood pressure levels were always fluctuating, so he came in to our busy staff model HMO every week for a checkup. He insisted on having his annual physicals down south, and only wanted me to take care of his "regular" problems: diabetes, hypertension, and hypercholesterolemia. We both suspected those conditions could lead to a heart attack some day, since he had a family history of heart disease. But he had the right to limit what I did for him, even if I didn't like it.

A call for help from Florida, and a last trip home

One winter morning my medical assistant told me that Helen was calling from Florida.

"Doc," she said, "Harry's in the hospital, and I'm really worried."

"What's going on?" I asked.

"He had some back pain a few months ago, just after we came down here. Then lately he couldn't urinate. He went to the doctors here, and they found prostate cancer that's spread to the bone in his back."

"So how is he now?" I asked.

"Not good," Helen replied. "He's in very bad pain, and I'm afraid he's dying. I can't stand seeing him like this. We'll fly up there today, and I want you to get him a room in your hospital so you can take care of him. You're the only one I really trust."

I was touched that Harry and Helen thought so much of me, a rare bond these days when doctors are so often considered interchangeable parts. I made the arrangements, and within 24 hours Harry was flown back to New York and admitted to our hospital.

It was early in the morning when I made my rounds, and Helen hadn't arrived yet. I had difficulty hiding my shock when I first saw Harry lying in bed. He weighed only half what he had when I'd last seen him. He was pale, and his great mane of white hair was matted down. The agony on his face made it obvious that he wasn't getting enough pain medication.

When he saw me, Harry sat up with great effort and shook my hand. He admitted to having had some symptoms for more than a year, but said he'd thought they were just "growing old pains." He never said anything because he hadn't wanted Helen to worry. But when he couldn't urinate, he'd gone to the hospital in Florida. A sonogram and bone scan revealed the already metastasized prostate cancer.

Coming back from a coma, in time for closure

I went out to the nursing station and got some morphine and injected it into Harry's IV line. I wrote orders for more pain control, and called the HMO's oncologist, urologist, and cardiologist to come and see him. The next day, Harry was in a coma. He had a living will in force, and had signed a DNR, so he wouldn't be accepted into the ICU. Helen was distraught.

"You can't let him go like this, Doc, you just can't," she begged. "We haven't had time, you see. We had a lot to say, but no time to say it. You have to save him. He can't go yet."

Harry was in septic shock: febrile, hypotensive, and tachycardic. His living will allowed us to give him only nutrition, fluids, and medications. The nursing staff informed me that hanging dopamine wasn't allowed on the floor, it could only be administered in the ICU.

"Aren't we allowed to have low-dose dopamine drips on the floor?" I asked.

"Yes," the nursing supervisor admitted.

So Harry received triple antibiotics, low-dose dopamine, and the prayers of Helen and many others. I visited him three times a day, and somehow the infusion rate always ended up set a little higher than it should have been for low-dose infusion dopamine. The nursing staff didn't seem to notice, or mind.

Harry remained in a coma for four days. His glucose levels were out of control. He developed rapid atrial fibrillation, and required digoxin. Helen never left his bedside.

On the fourth day, to everyone's surprise, Harry woke up and wondered what all the fuss was about. It was one of the greatest moments of my career. I'd spent more time with him than with any other patient I'd hospitalized, and it had paid off.

I still remember the day they wheeled Harry out of the hospital on a stretcher for the trip home by ambulance. He put on his big smile and waved goodbye to all the staff on the floor. Standing next to me, the supervisor admitted that she'd never thought she'd see Harry leave the hospital alive.

"Great nursing care," I said.

She looked at me, and I saw something in her face that I'd never seen before—real respect.

"No, doctor. It was good aggressive medical care."

Sometimes we do things right. Harry lived another few weeks: time enough for the closure so necessary to Helen and the family. I believe that Harry somehow knew this, and he'd come back for them. He finally died in his own bed, surrounded by his loved ones.

In the days before antibiotics and malpractice suits, the country doctor was familiar with everyone he treated. He used compassion as a powerful healing tool, because he had little else to offer. Nowadays we have plenty of medicinal arrows in our quiver, but in the hubbub of a busy workday, it's easy to forget about the compassion. There are so many patients, so much paperwork, and so little time. It's much faster and easier to report lab results, maintain clinical distance, put the cold stethoscope to the chest, and write a quick script.

Whenever I fall into that routine, and start asking myself, "Why am I doing this?" I remember Harry, and his smile. In the final analysis, it's not the condition of the road that's important, but the rich human experiences on the journey that sustains us. That makes me content to travel the road I've chosen.

 

Kenneth Pickover. Sometimes we do things right. Medical Economics 2002;16:55.