Category Archives: End of Life Care

A Doctor’s “Creed” – A Medical Review  

Creed

“I’ll fight, if you fight.”  Adonis Creed, to Rocky Balboa.

“First, do no harm.”  Hippocrates.

————————-

History of the Present Movie

The newest addition to the “Rocky” franchise, Creed, has gathered critical commendation as the best entry in years.  Like many of my generation, I was a convert to the original Rocky (1977), rooting for the workingman’s underdog from Philly against the Hollywood champ, Apollo Creed.  I delighted in the moral victory earned for completing the fight, despite the official loss on the judge’s score cards.  I absorbed all the iconic scenes: running up the courthouse stairs, chasing a chicken around the yard, and punching the slabs of beef.    Like many, I followed Rocky Balboa’s transformation over the years, holding my nose at his transformation into a cultural icon and buffoon-like superhero.  Even as future medical student, the horrific violence that was at the center of the storyline never troubled me.

It was with some trepidation, then, that I let my 12-year old son talk me into seeing this newest entry.  It was his preference over that other movie-saga of my youth, Star Wars.  But I had heard good reviews, including from a social worker colleague and an overheard locker-room comment that Stallone was a candidate for an Oscar for his role, a nomination which would be his first since Rocky.  The nuanced updating of Rocky as a mentor to Apollo’s kid promised a breath of fresh air into the storyline.  “Fine,” I thought, I’ll give it a try.”

 Review of Symptoms (No Spoilers)

The critics are right – it is the best Rocky movie since the original.  It is an inspiring story on two related fronts: the importance of pursuing your own vision while owning one’s past.  These themes play out in both main characters, Adonis and Rocky.  Over the course of the movie, each avoids owning their past, leading to difficulties in dealing with the present.  Conflicts arise, especially between the two, as the past threatens the future. As the climactic fight sequence arrives, both slowly own their past, and that emotional catharsis clears the field for moving into the future.  While predictable, the understated dialogue and tough-love demeanor make it work.  And then the overstated punches get thrown.

The director faces a similar challenge, trying to advance the new themes, while echoing the past,without descending into a cheesy reproduction.   The allusions to the private Rocky vs Apollo “third fight” that freeze-frames to end the second film is a nice touch – didn’t you really want to know who won the deciding match?   An appearance of the actual Rocky Balboa statue, with photographing tourists, is a perfect touch.  The re-ascent of the Courthouse stairs is imagined with a deft nostalgic touch.   Overall, the call-backs work, fitting smoothly into the narrative flow.rocky1

One bit of nostalgia doesn’t quite fit: I’m not sure Stallone’s performance is Oscar-worthy.  His genuine skill as an actor shakes off decades of shlock, a surprising butterfly, perhaps with crippled wings, emerging from its shell.  His understated charm works as an older man passing on the torch of fame.  One roots for the character and the actor to pull it off, and it really happens.  The buzz for awards is a consequence from the low expectations he’s set over the years.  But ultimately, this is Stallone as Rocky, a near-enough match to credit too much to acting brilliance.  It’s a ultimately a bit sad to see Stallone, the genuine actor, whose been lost over the years to the action-hero automaton.

 Medical Decision Making (Spoiler Alert)

My biggest problem with the movie was from a medical perspective.  A number of issues distracted me from the storyline, and they stemmed from the lousy doctoring, bad medicine, and questionable morality.

  1. First, Do No Harm — Cancer is featured as a significant part of the storyline. After a sparring session in which Rocky ends by vomiting and passing out, he is hospitalized. Following a hospitalization, he returns to the doctor’s office to find out he has non-Hodgkin’s lymphoma, a type of cancer of lymph nodes.  He is told by the doctor that he needs surgery and chemotherapy.  He refuses to consider treatment, saying that he saw his wife Adrian go through that, and “it didn’t go so well.”  He asks the flabbergasted doctor to keep this private.  She apparently agrees to do so, but gives him some pamphlets to read.  He sticks them in his pocket and heads out.  Most of the scene plays out with both parties standing up, rather than sitting for a heart-to-heart conversation.
  • So many things bothered me about this scene: the doctor’s paternalistic approach to the care, the blunt delivering of a life-threatening diagnosis, and the heavy-handed insistence on treatment without further discussion.  What about shared decision making?  What about asking about the patient’s experience?   When the patient says he had a prior “bad experience” with his wife, aren’t you going to explore this?  I was applauding internally when Rocky walked out the door, until I realized HE was supposed to the one acting inappropriately.
  • Ok, I admit that it’s a movie, that nobody wants to observe a 15 minute shared-decision-making conversation, and the plot needs to move along.  I also understand that doctor’s sometimes, perhaps often, act in this heavy-handed way, as Amy Berman has so eloquently taught us.  But I was appalled to see this portrayed so clumsily in a movie for mass consumption.  It feeds into the perception that cancer is a death-sentence, that heavy-doses of chemotherapy is the only way to cure the disease, and anyone thinking otherwise is misguided as best and foolish at worst.  This is a dangerous perception, with each element of the above containing falsehoods.
  1. The “War against Cancer” – A primary storyline for the movie is that Rocky’s legendary hardheadedness is at fault for his decision-making about cancer – that he is “giving up” by refusing to undergo chemotherapy. Adonis threatens not to fight in the championship bout unless Rocky “fights” against his cancer – i.e. he chooses to get accept chemo. Stemming back to the “War on Cancer”, we have continued to propagate the imagery of “fighting” or “battling” against an enemy, with the image of “giving up” or “quitting” on the other side of the ledger.  Given an opportunity to use Rocky’s cancer diagnosis as a metaphor for wisdom, understanding, and communication, the film falls into the same cultural trap of a war.
  1. Head trauma – Who can forget Rocky, in the midst of being pummeled by Apollo, his eyes swollen shut, telling his trainer to “cut me, Micky” – to cut his eyelids so he can see? The dramatic scene is a consequence of all the head trauma from the fight. One of the themes of Creed is that Apollo DIED from being punched in the head, which is why Adonis’s step-mother won’t let him fight.  One of the least believable parts of the movie, frankly, is that Rocky has lived long enough to get cancer, rather than suffering from Traumatic Brain Injury from repeated concussions.
  • The film doesn’t shy away from illustrating the damage occurring.  In the final dramatic scene, Adonis is knocked cold, blood flying, (with significant screaming from a woman in our theater) – only to literally spring up from the mat to finish the fight.  With his formerly anti-violence step-mother at home cheering him on, he finishes the fight, eyes swollen shut and massive bruising on his face (and presumably to his brain).  It was difficult to walk out of the theater, directly past the marquee for the movie Concussion, and not reflect on the glorification of head trauma we had just witnessed.

Thankfully, after the movie, I asked my son what he thought about boxing, and he said, “I’ll stick with gymnastics.”

Leave a comment

Filed under Decision Making, End of Life Care, Geriatric Oncology

Existential Pain and History

mte5ndg0mdu0otg3mjq1mdcx“I am a dead man!” Alexander recognized immediately that his condition was mortal.

At first, the patient suffered such exquisite pain that Dr. Hosack did not strip off his bloody garments…When [the patient] complained of acute back discomfort, [the doctor] and other attendants took off his clothes, darkened the room, and began to administer [medicines] to dull the ache.

[The patient] was preoccupied with spiritual matters…No sooner was he brought to the Bayard house than he made it a matter of urgent concern to receive last rites from the…Church.

When [the pastor] entered the chamber, he took [the patient]’s hand, and the two men exchanged a ‘melancholy salutation’… He explained that…”It is a principle in our churches never to administer the Lord’s Supper privately to any person under any circumstances.” [The patient’s] friends thought it heartless to refuse a dying man’s last wish.

As befits a great orator, Alexander roused himself for one last burst of persuasion.

At that point, [the pastor] relented and gave holy communion to Alexander, who then lay back serenely and declared that he was happy.

——————-

One common felt pain for patients at the end of their lives is existential or spiritual pain. Though difficult to define, most of us practicing palliative medicine recognize it when we see it. The proper intervention for it is not additional opiates, but rather appropriate spiritual support.

It always impresses me, when reading history, just how often our common humanity binds us across time. The patient above is Alexander Hamilton, lying on his death bed following his infamous “Interview at Weehawken” with Vice-President Aaron Burr . This slightly edited account, taken from Ron Chernow’s masterful biography, Alexander Hamilton, is a dramatic rendering of a man in existential crisis at life’s end. Hamilton recognized instinctively, as he so often did, his need for spiritual input to his pain. Unfortunately, in today’s medical world, we too often fail to recognize this need, delivering the wrong intervention, in the form of another dose of dilaudid, to patients needing spiritual uplifting.

This is not the first time I’ve noticed this in reading through historical biography. U.S. Grant eloquently describes a palliative approach to end-of-life care, as he completes his famous Memoirs while dying from head-and-neck cancer. John Adams describes a receding of the fear of dying, to be replaced by a fear of dementia. Human life, and death, resonates across the ages.

As I prepare for another stint on our Supportive Care Unit, a typically draining two weeks full of existential pain, I find reflecting on our common humanity, and the special role physicians are privileged to play in it, helps sustain me through the experience.

1 Comment

Filed under Books, End of Life Care, History, Palliative Care, Uncategorized

Robin Williams, Jimmy Wales, and Holes in the Universe

Many years ago, during my first stint living in the Windy City, Jimmy Wales of Wikipedia fame lived with us.  During that time, he told us a funny story.  He was in a park in a major city, I believe it was Central Park, but I can’t be certain.  He saw an aggressive mime bothering someone in the way mimes do, although this one seemed even more active and annoying than usual.  Suddenly, the man serving as the “audience” for the mime just slugged the mime, knocking him down.  I laughed – haven’t we all wanted to do this at some point in our lives?

This would have just been a cute story, except that Jimmy related seeing Williams on a talk show many years later – TELLING THE SAME STORY!  Only in that version, Williams was the mime being slugged.  I was laughing hysterically now, imaging my favorite comedian, being punched by some stranger who never knew his brush with fame.

All these many years later, I’m as stunned as everyone else at Mr. Williams’ death from suicide. Even as a physician who cares for many patients with depression, knowing the dangers it brings, I feel as sucker-punched as Williams-as-mime must have.

I vividly remember the first time I saw Williams on TV – in his role as Mork from Ork on my favorite childhood show, Happy Days.  His appearance on that family sit-com, in justice, should have been the “jump-the-shark” moment for the original “jump-the-shark” moment.  We would be calling such derailments of successful shows that have over-run their course the “alien-from-Ork” moments, I believe – except that Williams was just so damn funny.

I heard that, during the try-outs for the part of Mork, each applicant was asked to sit like an alien.  Williams spontaneously chose his now-famous head-down/ass-up posture, which nearly won him the role by itself.

There is nobody I can think of who filled my life with laughter as much as Robin Williams.  I watched Mork and Mindy religiously.  Even as a kid, I would stay up late, after begging my parents, to see him on the Tonight Show with Johnny Carson.  I watched every one of the charity specials that he co-hosted with Billy Crystal and Whoopie Goldberg.  I have seen virtually all of his movies, especially the comedies. I love to laugh, and nobody made me laugh more than he did.  The manic craziness, combined with the abstract flight-of-ideas, and the obvious delight in response of an audience – any audience – was infectious beyond belief.  There is just nothing like it.

I have read that one of the “reasons”, if such can be adduced after someone suffering from depression kills themselves, that he committed suicide was a recent diagnosis of Parkinson’s Disease. Since I treat many people with this disease, I wanted to comment that I hope that’s not true.  Many people with PD have a wonderful quality-of-life with the diagnosis, receiving treatments for it.  But I can’t help but wonder if, after playing the role of neurologist Oliver Sacks in the movie Awakenings, Robin was reminded of the unfortunate outcomes from that initial episode of using carbidopa/levodopa to treat a variant of PD.  But it is haunting to watch that film and not wonder a bit.

Now that Mr. Williams has written the final chapter of his life, he has left a hole in the universe, it seems.  His life, as much as anyone’s, was a singularity – and like the outer space version of such, it has left a black hole behind.  I wonder at this feeling of loss, this presence-of-an-absence, that some people leave behind.  It’s the converse of the bright flare of joy such people bring to our lives, and I’m going to try and le that shine on in my memory, as much as possible.  He really was the funniest person I’ve ever seen, and I see in my mind’s eye, him being punched for being TOO good a mime, with an astonished Jimmy Wales looking on, heading out to change the world in another way.  And you can read all about one due to the vision of the other.

Leave a comment

Filed under Comedy, Decision Making, End of Life Care, Philosophy

John Adams on Aging, Illness and Death: A Geriatrician’s Unusual Book Review

“My House is a Region of Sorrow, Inhabited by a sorrowful Widower…The bitterness of death is past. The grim spider so terrible to human nature has no sting left for me.”

–John Adams to his son, John Quincy, upon the death of his beloved wife, Abigail.

A Geriatrician’s Perspective

In First Family, Pulitzer-winning historian Joseph Ellis elucidates the character of our least-venerated, least-appreciated Founding Father, John Adams.  He brings Adams to life by presenting his life appropriately intertwined with one of our most-beloved First Ladies in history, Abigail (Smith) Adams.  As with all Ellis’s books, it is written with clarity, verve, and eloquence, mixing the Adams’ remarkable public career with his no-less remarkable marriage and personal life. How many people can claim that they effectively chose a country’s founding document (Jefferson), Military Commander (Washington), and Chief Justice (Marshall) and to have fathered a future President (John Quincy)?  And these are merely sidelights to a remarkable life of achievement. Rather than discuss the usual political topics, I focus here on a favorite topic of mine: aging.  Among the gems of insight scattered throughout this book are Adams’ (and Jefferson’s) thoughts on getting older, failing health, and death.  For a man who lived past the age of 90, at a time when life expectancy was closer to 40, his thoughts sound remarkably modern, hinting at the universality of these issues.

Adams and Jefferson on Aging

In the twilight of their lives, John Adams and Thomas Jefferson famously corresponded, reflecting on their lives and debating their political differences.  The correspondence had ended when Jefferson and Abigail Adams — John’s lifelong partner in all things domestic and political – exchanged letters, unbeknownst to John.  Jefferson denied paying a known “journalist” scoundrel, James Callendar, to libel John – which was a lie.  Abigail directly called Jefferson out on this lie, writing that, after their many years of friendship, “the Heart is long, very long in receiving the conviction that is forced upon it by Reason.”  After noting that Jefferson’s critics had accused him of being a disingenuous and dishonorable, steely-eyed Abigail says, “Pardon me, Sir…I fear you are.” Nobody he admired had ever been so direct with Jefferson on this point.  The result was that no further correspondence between households occurred for nearly a decade. Wouldn’t we all love to have such eloquent, steadfast support from our partner! After many years of bitter silence over such issues, Adams reignited a conversation, writing to Jefferson that, “You and I ought not to die before We have explained ourselves to each other.”  The resulting correspondence between the two, 158 letters worth in total, memorably did just this, as each posed for posterity, knowing their letters would be read by History.  While most discussions of this correspondence focus on the political ideas between the two, such abstract thoughts were interwoven with other topics.  This included sublime thoughts on aging, health, and death. In one exchange, Jefferson offers (p. 238): “But our machines have now been running for 70 or 80 years, and we must expect that, worn as they are, here a pivot, there a wheel, now a pinion, next a spring, will be giving way. And however we may tinker them up for a while, all will at last surcease motion.”  In my clinic, helping my older patients navigate through issues of their “machines” running down, dealing with multimorbidity, frailty and polypharmacy, I often feel just like some mechanic, “tinkering” with their delicate “parts”, hoping to keep them moving as long as possible.  Many patients of mine, especially the men and the engineers, complain about their declining abilities like cars springing leaks, rusting through, and falling apart. In response, Adams worries about something slightly different: “I am sometimes afraid that my ‘Machine’ will not ’surcease motion’ soon enough; for I dread nothing so much as ‘dying at the top,’ and thereby becoming a weeping helpless object of compassion for years.”  Adams’ had an ongoing fear of losing his mental faculties. As Ellis notes, Adams had seen the mental deterioration of his cousin, Sam Adams, and John “feared dementia more than death.”  This is the sentiment I so often hear from my patients, that their greatest fear is getting Alzheimer’s disease. My own experience with patients confirms this as one of their greatest fears as they grow old.

Literary Illness

Among the literary gems unearthed by Ellis are Adams’ colorful descriptions of his various ailments.  He creates a lovely neologism to explain one particular problem:  the “quiverations” in his hands.  These tremors prevented this inveterate, lifelong writer from doing so effectively.  He had to resort to dictating his ideas to whatever grandchild he could convince to listen.  I love this term, which captures the spirit of how tremulousness must feel from within. I’ve had patients say how they simultaneously don’t notice their tremors, but how annoying it is when they have to deal with it.  I’m likely to adopt this term for my patients, as I love the verve it imparts to the condition. In another case, he complains that his “constitution is a glass bubble or a hollow icicle”.  He worries that, “A slight irregularity or one intemperate dinner might finish the catastrophe of the play.”  He was on the brink, in which a new stressor might push him over the top.  I can think of no more poetic expression of Fried’s Frailty, which is a physiological vulnerability to stressors which predisposes older adults to morbidity and mortality.  Thinking of my frail patients as “glass bubbles” is a perfect metaphor for those struggling through another Polar Vortex in Chicago.

Death, Dying, and the Spirituality

When Abigail died, as the quote above indicated, Adams was grief-stricken for nearly a year.  After 54 years of marriage, he was lost without his lifelong confidant.  Grief at the death of a spouse or other loved one is a constant risk for older adults, especially if it leads to on-going depression.  It is a wonderful reminder of the blow such events can deal to our older patients. Adams despite a having a Deacon for a father (whom he deeply admired), had skeptical views of religion and the afterlife. In his later years, when asked about the Christian view on life after death, he jokingly responded that he assumed God would allow him to further debate Benjamin Franklin as part of the experience. Nevertheless, he did assume there was some sort of afterlife: “If it should be revealed…that there is no future state, my advice to every man, woman, and child would be…to take opium.” On the day of the 50th Anniversary of the Declaration of Independence, which Jefferson was chosen to author by Adams, the two Founders died within hours or each other, on July 4th, 1826.  Adams famous last words, “Thomas Jefferson survives,” were incorrect; Jefferson had passed shortly before his colleague.  Like two intertwined spouses, the two friends left their earthly lives together.

1 Comment

Filed under End of Life Care, Geriatrics, History, Palliative Care, Uncategorized

History Lessons: General Ulysses S. Grant on a Palliative Care Approach for Terminal Cancer

Ulysses+S.+Grant Memorial Day famous war heroes

History is a great teacher.  Whenever I start to believe that our contemporary issues are new to humanity, I seem to immediately encounter a historical example.

I just finished reading a biography of Civil War General and President Ulysses S. Grant.  A lifelong cigar smoker and moderate imbiber, he died of head and neck cancer.  Memorably, he wrote his autobiography, encouraged by his editor Mark Twain, which is considered perhaps the best presidential example of the genre of all time, while consciously dying from his cancer.

Unbeknownst to me, he also took time out from writing his memoirs to write some personal thoughts into a diary, including about his cancer.  The insights into palliative medicine are remarkable, especially given the continuing ignorance of them in our own day.  He writes in a remarkably clear-headed way.

Treating the Pain

Describing the pain and symptoms he was having he says, “…I have watched my pains and compared them with those of the past few weeks. I can feel plainly that my system is preparing for dissolution in three ways: one by hemorrhage, one by strangulation, and the third by exhaustion.”  This is a stunningly prescient and dispassionately clinical description of his prognosis, and one that I would be delighted to hear from an intern on my service.

Then, for his doctors, he makes crystal clear his care preferences, “I have fallen off in weight and strength very rapidly for the last two weeks.  There cannot be a hope of going far beyond this time.  All any physician, or any number of them, can do for me now is to make my burden of pain as light as possible.”

A clearer description of the desire for a palliative approach at the end of life couldn’t be made.

He worries openly about his current family doctor insisting on bringing in more specialists, “I dread them…knowing that it means another desperate effort to save me, and more suffering.”

As he weakened, he recorded his reactions to his pain medications.  As his doses of morphine escalated, outlines a distinction between addiction versus normal escalating needs for pain relief, “…when I do take [morphine], it is not from craving, but merely from the knowledge of the relief it gives.  If I should go without it all night I would become restless…from the continuous pain I would have to endure.”  My patients worry all the time about “becoming addicted” to pain medicines – it would serve me well to simply read this passage in reply.

Existential Suffering…and Triumph

One strategy for normalizing end-of-life situations, as difficult as it is to note at times, is to use humor, something Grant does expertly, “The fact I think I am a verb instead of a personal pronoun.  A verb is anything that signifies to be, to do or to suffer.  I signify all three.”

Yet all was not seen as bleak.

He appreciated all the more the trials and tribulations the country had endured through that horrible war, and he was glad to have seen it through. “It has enabled me to see for myself the happy harmony which has so suddenly sprung up between those engaged but a few short years ago in a deadly conflict.”

And he was appreciative of the sympathy he received from his recently united fellow citizens. “It has been an inestimable blessing to me to hear the kind of expressions towards me in person from all parts of the country; from people of all nationalities, of all religions, and of no religion, of Confederate and National troops alike, of soldiers’ organizations, of mechanical, scientific, religious and all other societies…They have brought joy to my heart, if they have not effected a cure.”  Reflecting on one’s life, even when not as eventful as the general’s, is often cathartic for patients.

And he had the occasional  “good days” that I urge my patients to embrace, sitting on his porch, “I feel pretty well…I am as bright and well now, for a time at least, as I ever will be.”

Engaging with Loved Ones to the End

Unable to talk, he wrote a loving farewell to he beloved wife, who was wracked with grief.  “With…the knowledge I have of your love and affections and the dutiful affections of all our children, I bid you a final farewell until we meet in another, and I trust better, world.”  Like many, he had spiritual needs to satisfy at the very end.

Having finished his memoir and sent it off to the printers, he signed off. “There is nothing more I should do now.  Therefore, I am not likely to be more ready to go than at this moment.”  He had shrunk down to under 100 pounds; too weak to sit, he retired to bed.

Three days later, his family gathered around him, he died.

2 Comments

Filed under End of Life Care, Geriatric Oncology, History, Palliative Care

Good Morning and Goodnight, Domino

“Good morning, Domino, what are you doing?”

I had rushed down the stairs to get my 20 minutes in on the treadmill.  I hadn’t seen him lounging on the couch.  I was perplexed why he was lying with his feet handing off the edge.  No response.  That’s weird.  He’s such a cat-napper. Must be really tired, poor guy.  Getting old. 

“What’s the matter, Domino?”

Then it struck me – he wasn’t just lying there, half-sleeping.  He was completely still.

My insides froze in realization.   I immediately reverted “doctor-mode”, moving closer and searching for breathing.  Or some kind of movement.  Not trusting my eyes and heart,  I laid my hand on his chest.

Nothing.

He was gone.   Our housemate of 17 years, whom I seen just hours ago as he went bounding down the basement steps, was dead.

I hadn’t seen it coming.  I felt ashamed.  How come I didn’t realize it was coming? 

——————————————-

He was one of those individuals who was so full of life, you just never thought he’d stop.  So alive – so infuriatingly alive, in the middle of everything, demanding, persistent, insistent, and loving — he didn’t do anything half-heartedly.  Even as he got older and thinner, with a little less sparkle in his eye, he remained adolescent in his ways.  Snuggling aggressively.  Whining demandingly.  Sneeking persistently.  Purring excessively.

How could that all be over?

Domino, the cat who would seemingly never die, who had hardly been sick his entire life, was dead.  Just like that.

It’s crazy, I thought, I’m a doctorNot just a doctor, but a geriatrician and palliative medicine specialist.  I’m always counseling people about prognosis and end-of-life.  I had just been saying how spry Domino was for an “old man”, how he would probably live at least another 5 years.  Of course, I had noticed that he was a little thinner, that he was developing cataracts, that he couldn’t jump onto the bed anymore.  But he seemed so, well, ALIVE.  How had I missed it?  What’s wrong with me?

——————————————-

How do I tell Tamra?

Domino was always hers.  She had picked him out that day – or rather, he had picked her out.  Came right over and introduced himself to her, the smallest of the litter.  She brought him back to our grad-student apartment, let him run around, allowed his bright blue eyes full of curiosity to win her over, letting her make the case to me for him to stay.  I was against it – we didn’t have time for a cat, we were both too busy, too wrapped up in our own concerns, ambitious young folks making our way to careers in academic medicine and business in the middle of the bustling City.  We already had a cat, inherited from a friend, an adult animal that lived with us, tolerated us, but wasn’t part of us.

They both looked up at me, his mischievous blue eyes beside her beseeching brown ones.

I didn’t have a chance.  We were now his family.

The thing about pets – they are always there, and they’re always the same.  Over all of those 17 years, Domino never changed – he lived the most consistent life.   He was always there, a constant source of energy, trouble, and love – through our student-apartment life, our move to our first grown-up house, to another apartment in Steel City with real jobs, to another house in that city, and a final destination in a bigger house, back in Chicago where we started.   Thinking through those many years, like a time-lapse film running  at super-speed, he’s a remarkable constant.  Same personality.  Same insistent demands.  Same acceptance when demands were met.  No worries about anything else.  Quick to cuddle and purr, regardless of what happened before.

I’d gotten so used to him.  So reassuring to know he was there with Tamra when I couldn’t be.  That constancy was assumed.  Over time, it was required.  Having that constancy gone, out of the blue, is…terribly…upsetting.

——————————————-

I went upstairs, heart flailing, into the usual frenetic pace of another morning with the boys.   I walked slowly into the schoolroom.  She was there, working with the twins on their lessons, as usual.  I didn’t want to scare them.

I failed.

“Tam.”  My voice sounded weird, even to me.  They all turned, concern in their eyes.

“What’s the matter?”

“Can I talk with you…privately?”   I motioned with my head out in the hall.

“Sure.”

Realizing a had less than a minute before the boys would descend, I tried to sound normal.

“Domino died last night.”

“What?”

“He died last night.  He’s lying on the sofa downstairs.”

Like me, she didn’t believe it.  “Are you sure?”

Was I?  “I’m pretty sure.”

“I want to see him.”

——————————————-

“Should we tell the kids?” she asked.  I had wondered the same thing.  It was just about time to pack them up and take them to school – how would they respond?

“Yes, of course, it’s what we call a ‘teachable moment’ in the hospital.”  Somehow the obvious thing to do, to expose one’s children to all of life’s events, is questioned when we’re struggling with our own feelings of inadequacy.

I gathered our 3 boys together around me, squatting down to look them square in the eye.

“Listen guys, I have something important to tell you.”

Serious nods.

“Domino died.”

“He DIED!?!”

“Yes.”

“Where is he?  Can we see him?”

I took them downstairs, and they wanted to touch him, to experience it for themselves.  Smart.  Appropriate.   Their individual reactions were perfectly in character – amazing how they never break character, I thought.

Harrison (5): (While sucking on his thumb.)  “It makes me sad.  At least we’ll still be able to play with Grandma’s kitties.”

Xander (8): “What happened?”  [I don’t know]  “When did it happen?” [Some time last night.]  “Why are his eyes open?”  [That’s what happens sometimes when people and animals die.]  “Is he warm?”  [Go ahead and touch him.]  Etc, etc, etc.  Ever the nervous questioner.

Austin(5): “Can we get a dog?”

I noticed my wife didn’t want to touch him.  Later, she confessed to me that he always purred when she touched him, that he wouldn’t, and she knew she would bawl if she touched him.

I’m glad we had the boys experience this.  The author E.B. White, of Charlotte’s Web and Strunk & White’s Elements of Style,  once said that one should always treat children with respect by talking about adult things in terms they can understand.  As usual, Mr. White was correct.

I will try to keep this in mind when considering end-of-life discussions with families.  If they ask, always let the kids participate.  They often bring an honesty and openness that adults lack.

——————————————-

I spent the rest of the day feeling remarkably melancholy, unable to shake my feelings of sadness, loss, and guilt.  A little over a year ago, my father passed away, a victim of cancer (http://chicago.academia.edu/WilliamDale/Papers/855803/My_Fathers_Life_and_Death_from_Cancer ); in certain respects, my emotions are more disheveled over Domino.  Because I care for cancer patients regularly, I knew well before my family that my father would die from his cancer, and I had prepared for it.  I was completely shocked to find my cat had died.  Although I thought about my father a lot, we had become estranged over time, and we didn’t talk regularly, so his death did not change my daily life and routines signficantly.  Domino, in contrast, was a constant presence our lives, especially my wife’s life.  It’s impossible right now to walk through the house and not be constantly reminded of him.  And, unlike my father, who could be temperamental and unpredictable, the cat was consistently contented and friendly, a soothing presence always.   The combination of his constant, supportive nature and his unexpected sudden departure, is making these feelings very difficult to shake.

I really want to be a more consistent source of support to my friends, family, and colleagues.  A steadying influence can be instrumental in helping people make it through the day.  And when working with families as their doctor, I need to keep in mind just how difficult a death, especially an unexpected death will be, how much of a “hole in the universe” the loss of a loved one will create, and how empty one will feel.

————————————-

We reflected on Domno’s life tonight.  It was a great life – better than most of us get.  He was happy, vibrant, and engaged right up until the very end.   He was able to live life on his own terms.  And he died at home, not in any pain, around loved ones, in his sleep.  I will do better to emulate these characteristics, and hope my own earthly departure will be as short, simple and easy.  And I will work harder to help my patients have the same sort of “healthy death.”

“How are you doing?”

“I’m so sad.  I’m really going to miss him.”

“Me too.”

6 Comments

Filed under End of Life Care, Pets