January 18, 2016

Living and Dying

Living and Dying

His white hair glistened brightly amidst the darkness of the room. The sun had just risen with rays creeping through shuttered blinds, painting stripes along the opposite wall of the wonderfully cramped and plain VA hospital room. He was lying calmly in his bed, awake. When he heard me enter, he looked up and smiled. In his thick New Jersey accent, he said, “Well, hi there! If I knew you were coming, I’d have baked a pie!”    

“Sorry to wake you, Mr. G,” I replied as I handed him his hearing aids from the side of the bed. “How was your night?”

“Oh, well, you know,” he started. “The pain is still there but it’s not so bad.”

“Do you think the pain meds are working?”

“Oh yes,” he replied. “It really takes the edge off.”

Mr. G was 92 years old with a known metastatic prostate cancer diagnosed two years prior. He came in with severe lower back pain and urinary retention due to his enlarged prostate. His imaging was thankfully negative for compression of his spinal cord, but revealed a pathologic fracture of his tail-bone. He came onto our medicine team for acute pain management. He was started on an assertive pain control regimen and received palliative radiation, which made him considerably more comfortable.

“You think they’re ever gonna take this out?” he asked, pointing to the Foley catheter tube emerging from underneath his gown. It had been left in because his urethra was entirely obstructed by his prostate.

“I don’t know, sir,” I answered truthfully, “But for now, it’s helping you clear urine from your bladder. We think it’ll help you feel more comfortable.”

“Oh good, that’s fine.” He replied. “But do you think I can ever get out of here?”

“We’re working on it, sir.” I said, also truthful but with unwarranted optimism.

His story was exceedingly tricky for all of us because he also came in with a diagnosis of dementia. For this reason, his daughter was his health care power of attorney. She took the word “power” to heart. She refused to let her father be present at any family meetings. She refused to discuss any life-prolonging therapies and requested all treatment decisions go through her.  When asked why promising life-prolonging therapy was discontinued two years ago, she simply said, “My father would never want to live longer with his dementia.” She insisted his dementia was “severe,” that taking care of him was “impossible,” and that he was “unable to do anything by himself.”

The tricky aspect was that he was none of these things during his hospital stay. He was continuously alert and oriented and had only mild short-term memory loss. He was able to recall events that took place 70 years ago, 3 years ago, and earlier in the day. Prior to being hospitalized, he was living in an assisted living facility with his wife of 70 years. Despite his daughter’s claim, he was aware he had cancer and aware that he was dying.

“What bothers you the most, sir,” I asked.

“You know, doc, the pain of not seeing my wife,” he said, part dejected, part wistful. “It’s worse than the pain in my back.”

“I know how much you love her, Mr. G,” I replied. “She sounds like such a wonderful person.”

“70 years, doc! That’s how long we’ve been married. And you know what – it seems like it was yesterday.”

We both smiled as I patted him on the shoulder.

“The spark is still there,” he said. He first looked down at his bed sheets and then back up at me. His eyes were not tearful but expressed grave concern. “Do you think we’ll get to live together again?”

I offered encouragement again, but I did not know the answer to this one. It was another tricky situation related to his daughter. From our vantage point, Mr. G was fully capable of living with his wife in assisted living with home hospice care. However, his daughter found this idea heretical and demanded her father live in a skilled nursing facility — away from his wife. Despite our insistence that there was no legitimate medical or physical/occupational therapy rationale for him to require that level of care, she continued to drag her feet.

Though Mr. G was medically cleared, planning for his discharge was an absolute mess and fraught with ethical dilemma. To its credit, the VA hospital and its dedicated staff continued to remain firm in pushing for the patient’s dying wish — to spend his remaining days by his wife’s side. However, given the family dynamic and insistence on an option that did not honor his wishes, Mr. G was stuck in the hospital for the foreseeable future.

****

As a medical student, I was an observer, not an active participant, in those conversations and decisions. But being a medical student with considerably more time than everyone else on the team, I was able to play a role in his care — helping keep his mood up and his body active during his extended stay.

Despite his illness and prognosis, Mr. G was always delightful and pleasant to be around. He may have been 92 on paper, but he could give people half his age a run for their money. He loved to walk, so I would devote a couple hours each day to go for a walk with him. Sometimes, we’d go down to the cafeteria together and share some coffee and conversation. It was during this period that I learned his amazing life story.

Mr. G learned to be resilient from an early age. His father left his mother and him when he was only 11. His father sounded like a truly awful man. He didn’t see his father for 45 years until one day, his father knocked on his door and handed him a lawsuit. He claimed his son owed him money, but “once the judge heard me speak, he threw my dad’s ass out of the courtroom. I mean, can you believe his nerve?!”

Mr. G never went to college, instead working odd jobs and construction to help support his mother. He enrolled in the military and served in World War II. He was a combat engineer in the army and served with General George S. Patton. “People were scared of him, but he was always nice to me. If you did your job right, you kept him happy.”

Mr. G knew I went to Princeton for college – we bonded over being “NJ mosquitoes” as Mr. G put it. He loved telling me his Princeton-related war story. During the invasion of Normandy and subsequent battles, Mr. G was captured briefly by the Germans. The general in charge of the German contingent was a cocky, but intelligent man.

“Where are you from?” He had asked Mr. G.

“I’m from New Jersey,” Mr. G had replied, in as thick a Jersey accent as he could muster.

To his surprise, the general replied, “Oh, I know New Jersey!”

“You do?”

“Yes, I went to Princeton!”

“Oh wonderful,” Mr. G replied. “I’ve driven by Princeton.”

He never told me how he escaped from German detention, but perhaps it had something to do with the bond established between “NJ mosquitoes.”

Most of the stories Mr. G told me were not about war, but rather about his wife of 70 years. He clearly missed her but did enjoy telling me about her. They met in New Jersey at one of those old-fashioned roller-skating rinks. “I literally swept her off her feet!” By that he meant, he bumped into her and caused her to fall.

He told me how his wife was originally from Germany but had emigrated early in the 20th century. He also proudly told me how his wife worked on the Manhattan project, playing a crucial role in developing the atomic bomb. He was mindful of the destruction caused in Hiroshima, but he did maintain, “General Patton told us if we hadn’t dropped that bomb, a million more lives would have been lost in war.”

His stories about his wife and the obvious, radiant energy to their love were captivating and inspiring. But it did give Mr. G good cause to comment on my marital status (i.e. single). He said he knew that doctors are always so busy with their work, but that was no excuse. “You have to be proactive. You can’t let it slip you by because it will.”

I looked forward to my afternoons with Mr. G, whether walking up and down the hospital floor or heading down to the cafeteria for some coffee. He really enjoyed the latter — I’ve never seen someone quite so excited to go to VA hospital cafeteria. But when someone is stuck in his room against his wishes, it’s pretty easy to appreciate the sentiment.

He was always effusive in his appreciation and praise, saying spending time with me was the highlight of his day. I made sure he knew spending time with him was the highlight of mine. He told me about his favorite doctor, Dr. Shocken, up in small town NJ. When Mr. G ran his construction business, he developed a friendship with Dr. Shocken. Despite being a brilliant, compassionate mind, his friend had trouble landing a job because of his Jewish faith. Mr. G was working on constructing a new wing for a community hospital, and he aided Dr. Shocken in getting a job there.

“He was a brilliant man and oh, so, so nice — he was a doctor’s doctor, if you know what I mean,” Mr. G would say. “And you know what, I think you are going to be one too.”

****

I loved my few weeks working at the VA because of getting to know patients like Mr. G. His life read like a vibrant novel, and the love he had for his wife was genuine, beautiful, and insurmountable. It was oddly refreshing to meet someone who knew he was dying, accepted it, and knew with immense clarity how he wanted to pass, and with whom by his side.

It was hard not to get emotionally invested in his case, knowing that he was being deprived of his dying wish. I was proud to work at a VA facility that understood this and fought for that right. But in the unfortunate nightmare that can be real-life, he was stuck in a hospital waiting for social and political factors to get worked out. I’m happy in the interim I could provide a service to him, and through him, I learned so much about both living and dying.

Vinayak Venkataraman is an MS2 who enjoys writing, cooking Indian food, playing tennis, drinking coffee, and cheering for the Buffalo Bills.