ON BEING A DOCTOR
Annals of Internal Medicine
Surrender
B
“
ob” is not a very Japanese name. That was my first clue to his westernization. “Welcome to our home, doctor,” he said in a thick accent. However, he spoke rapidly, suggesting decades of English. He gave a deep, respectful bow as I mentally assessed his age. Seventy-five at most, he had migrated here as a little boy just after the war. “Konnichiwa,” I responded with a short bow in my best restaurant Japanese. I worked at the downtown Mikado during my teens. That was at least 30 years after the war. “Oh, your Japanese so good,” he said, as they all do, with a hearty laugh that is intended to compliment but is, in fact, real laughter. The hospice nurse, a New Zealander, said nothing and did not smile, walking past Bob into the house. Bob and Akiko lived in a small, brown-brick home on the south side of town, surrounded aptly these days by chainlink safety fences. Ironically, the compact bento of a house was once an open expanse of freedom for the extended family of emigrants who filled it. In the years after the great bomb forever changed the world, a family thrived and prospered here and a young boy who changed his name ran free in this once-peaceful neighborhood. “Please, come and meet my lovely wife,” Bob motioned down the hallway with excitement. “Lovely” was pronounced with three syllables, as if Ricky Ricardo had said it about Lucy. The face-to-face requirement for Medicare hospice recertification is a favorite part of my palliative work. For 6 months, I had managed these patients via interdisciplinary team meetings; now I was able to enter their homes and be part of their lives. “My darling, this is the doctor,” Bob told Akiko. “Very wonderful doctor come to see you and take care of you.” He knelt by her low bed and took her hand, speaking to her just a few inches from her face. Akiko was the tiniest adult human I had ever seen. I knew that her body mass index was less than 10, but I could not imagine what that would mean up close. All of her was small, her head, her torso, her tiny twig legs. I wondered not how such a tiny creature continued to survive but how she ever did survive: bearing children, walking upright, carrying groceries. “Konbanwa, Akiko.” I took Bob's place and held her hand, looking intently into miniature shrew eyes barely looking back at me. “It's so good to finally meet you.” She said nothing, seemingly lacking the strength to move her mouth and whisper or even to smile. Her legs were drawn up in fetal contractures. Her skin was remarkably smooth and well-lotioned, with no sign of breakdown, rash, or “senile purpura” so common to all of my patients. I performed my usual cursory examination, showing my use of the stethoscope here and there as if discovering a heart murmur or auscultating a few rales was meaningful.
“I won't disturb her anymore,” I said after just a minute. “Why don't we step out and talk?” Bob seemed agreeable to the brevity of disruption and led the way to the dining room. The nurse was visibly surprised that my “exam” took only seconds, but with a diagnosis of progressive supranuclear palsy and almost no oral intake, the face-to-face was superfluous to confirm a hospice-qualifying death within 6 months. The house, once tidy and organized in Akiko's day, was less well-kept by Bob. Bits and pieces spilled from one room to another: letters and papers, picture collages, furniture. A dozen chairs crowded the living room, no three matching. A pair of floor rockers I'd seen advertised on television (I pictured Bob excitedly dialing to get the free shipping). It was common to discover too much furniture in these homes: collected from decades of time, uncertain what to get rid of, too frugal to throw away and buy new, and still useful when the whole family gathered. Family photos covered one wall and overflowed into the hallway and kitchen. Haphazard frames, old and new, some with taped-up photographs updating the old. “Chelsie” was apparently a favorite granddaughter, or at least the one with the most photographs. She posed in a cheerleading outfit. “Very American,” I thought. Her father, Ichiro, was pictured next to her, and I couldn't help but wonder at the juxtaposition of names: Ichiro and Chelsie, Akiko and Bob. There was another son, but he was hardly seen in photographs. And perhaps a youngest daughter. “Please sit down,” Bob motioned. He did not wait for either of us to sit before he did. The table was littered with envelopes, bills, and notes. A dozen pill bottles of various sizes and labels made me wonder how anyone could organize the number of medications that I prescribe them. There were chocolate bars on the table; some hard candy in a crystal dish; and some truffles in an open box with a Christmas bow on it, now 7 months old. Bob did not offer me candy, a cup of tea, or anything typical for an Asian host. “Doctor, if you would please refill these medicines,” Bob got straight to the point as he handed three pill bottles my way. “Now, Bob, we've talked about this,” the nurse butted in with an irksome tone. “Some of these pills are not appropriate for Akiko anymore.” Appropriate. There was the word of the day. Now I recognized why I was here—not just a required face-toface visit but as a mediator in an ongoing battle. Bob, the American, the progressive, the believer in Western medicine's ability to save his wife. The nurse and Akiko, foreigners, traditionalists, trying to adhere to “comfort care only,” as is appropriate according to hospice principles. He wanted refills on donepezil, warfarin, and simvastatin—the drugs that we'd convinced them were life-sustaining. He asked me to renew Akiko's referrals to neurology and dermatology. He wondered why the physical therapist no longer came. Bob was on board © 2015 American College of Physicians 145
Downloaded From: https://annals.org/ by a Universite Laval Biblioteque User on 08/05/2017
ON BEING A DOCTOR with palliative care for the assistance but not really for terminal care. What did Akiko want? I judged her quality of life to be zero. If she were my own mother, I would provide comfort medicines only and hope for a speedy death under the care of hospice. But perhaps “dignity” to Bob meant seeking another MRI and more tests and subspecialty visits. He obviously took very good care of her, and “care” to him extended beyond creamed skin and forceful feeding. Would I rob him of that? The contrasts of old age can be stark: once competent, now totally dependent; once a servant, now in constant need. Once he trusted Western medicine to diagnose and cure, now he was skeptical as we urged him to give up. Revoking hospice might have sent Akiko back into frequent hospitalizations, expensive medicines, and unavailing subspecialty work-ups. Maintaining her on hospice meant repeated confrontations about end-of-life care. “Bob,” I said gently, with as much compassion as I could muster for that one-syllable name. The pang of wanting to do everything for him stopped my words for a moment. Cheerful and pandering until now, his face was suddenly stoic and solemn. I felt the tightness of the bento home and fleetingly compared it with my own spacious East Bench house. Old-time movies of a mushroom cloud and tiny cachectic people marching away from desolation ran through my mind. “What are a few extra medicines or specialist visits?” I asked myself. But then I remembered that Bob was not my patient, and I felt the duty and the will to help Akiko. “Bob,” I said, “you have served Akiko so well. You have fought a great battle. It's time now to let her be free.” A sigh of celebration from the nurse. Bob's stillstoic head was held high, but quickly an involuntary
Surrender
tear formed in his eye. And his visage softened to surrender. I expected anger. I expected to engage in a struggle. I thought I might even be kicked right out of the door. I did not expect resignation. “Doctor, you very good doctor, you Harvard doctor.” A tiny trembling smile showed that he had researched my name. He paused as if to judge whether I was an imposter. “I will do as you say, doctor.” He brought his hands together and gave a short bow, like a Samurai handing over his sword. I thought that the nurse might revel in “told-you-so” and spoil the moment. Instead, we all sat silently, mourning the end of life of one small but highly honored woman. I departed the same way I came, with hand clasps, head nods, and much thanks. I departed in peace, to my pleasant surprise. I did not see them again. Akiko passed just 2 weeks later. When I received the text message notifying me of her liberation, I felt no victory, only sadness for her faithful husband. I, too, put my hands together and bowed my head silently, a fellow soldier also in surrender. Richard Allen, MD, MPH Utah Healthcare Institute Salt Lake City, Utah Requests for Single Reprints: Richard Allen, MD, MPH, Utah
Healthcare Institute, 1250 East 3900 South, Suite 260, Salt Lake City, UT 84124; e-mail, [email protected]. Ann Intern Med. 2015;163:145-146. doi:10.7326/M15-0023
146 Annals of Internal Medicine • Vol. 163 No. 2 • 21 July 2015
Downloaded From: https://annals.org/ by a Universite Laval Biblioteque User on 08/05/2017
www.annals.org
Annals of Internal Medicine
Surrender
B
“
ob” is not a very Japanese name. That was my first clue to his westernization. “Welcome to our home, doctor,” he said in a thick accent. However, he spoke rapidly, suggesting decades of English. He gave a deep, respectful bow as I mentally assessed his age. Seventy-five at most, he had migrated here as a little boy just after the war. “Konnichiwa,” I responded with a short bow in my best restaurant Japanese. I worked at the downtown Mikado during my teens. That was at least 30 years after the war. “Oh, your Japanese so good,” he said, as they all do, with a hearty laugh that is intended to compliment but is, in fact, real laughter. The hospice nurse, a New Zealander, said nothing and did not smile, walking past Bob into the house. Bob and Akiko lived in a small, brown-brick home on the south side of town, surrounded aptly these days by chainlink safety fences. Ironically, the compact bento of a house was once an open expanse of freedom for the extended family of emigrants who filled it. In the years after the great bomb forever changed the world, a family thrived and prospered here and a young boy who changed his name ran free in this once-peaceful neighborhood. “Please, come and meet my lovely wife,” Bob motioned down the hallway with excitement. “Lovely” was pronounced with three syllables, as if Ricky Ricardo had said it about Lucy. The face-to-face requirement for Medicare hospice recertification is a favorite part of my palliative work. For 6 months, I had managed these patients via interdisciplinary team meetings; now I was able to enter their homes and be part of their lives. “My darling, this is the doctor,” Bob told Akiko. “Very wonderful doctor come to see you and take care of you.” He knelt by her low bed and took her hand, speaking to her just a few inches from her face. Akiko was the tiniest adult human I had ever seen. I knew that her body mass index was less than 10, but I could not imagine what that would mean up close. All of her was small, her head, her torso, her tiny twig legs. I wondered not how such a tiny creature continued to survive but how she ever did survive: bearing children, walking upright, carrying groceries. “Konbanwa, Akiko.” I took Bob's place and held her hand, looking intently into miniature shrew eyes barely looking back at me. “It's so good to finally meet you.” She said nothing, seemingly lacking the strength to move her mouth and whisper or even to smile. Her legs were drawn up in fetal contractures. Her skin was remarkably smooth and well-lotioned, with no sign of breakdown, rash, or “senile purpura” so common to all of my patients. I performed my usual cursory examination, showing my use of the stethoscope here and there as if discovering a heart murmur or auscultating a few rales was meaningful.
“I won't disturb her anymore,” I said after just a minute. “Why don't we step out and talk?” Bob seemed agreeable to the brevity of disruption and led the way to the dining room. The nurse was visibly surprised that my “exam” took only seconds, but with a diagnosis of progressive supranuclear palsy and almost no oral intake, the face-to-face was superfluous to confirm a hospice-qualifying death within 6 months. The house, once tidy and organized in Akiko's day, was less well-kept by Bob. Bits and pieces spilled from one room to another: letters and papers, picture collages, furniture. A dozen chairs crowded the living room, no three matching. A pair of floor rockers I'd seen advertised on television (I pictured Bob excitedly dialing to get the free shipping). It was common to discover too much furniture in these homes: collected from decades of time, uncertain what to get rid of, too frugal to throw away and buy new, and still useful when the whole family gathered. Family photos covered one wall and overflowed into the hallway and kitchen. Haphazard frames, old and new, some with taped-up photographs updating the old. “Chelsie” was apparently a favorite granddaughter, or at least the one with the most photographs. She posed in a cheerleading outfit. “Very American,” I thought. Her father, Ichiro, was pictured next to her, and I couldn't help but wonder at the juxtaposition of names: Ichiro and Chelsie, Akiko and Bob. There was another son, but he was hardly seen in photographs. And perhaps a youngest daughter. “Please sit down,” Bob motioned. He did not wait for either of us to sit before he did. The table was littered with envelopes, bills, and notes. A dozen pill bottles of various sizes and labels made me wonder how anyone could organize the number of medications that I prescribe them. There were chocolate bars on the table; some hard candy in a crystal dish; and some truffles in an open box with a Christmas bow on it, now 7 months old. Bob did not offer me candy, a cup of tea, or anything typical for an Asian host. “Doctor, if you would please refill these medicines,” Bob got straight to the point as he handed three pill bottles my way. “Now, Bob, we've talked about this,” the nurse butted in with an irksome tone. “Some of these pills are not appropriate for Akiko anymore.” Appropriate. There was the word of the day. Now I recognized why I was here—not just a required face-toface visit but as a mediator in an ongoing battle. Bob, the American, the progressive, the believer in Western medicine's ability to save his wife. The nurse and Akiko, foreigners, traditionalists, trying to adhere to “comfort care only,” as is appropriate according to hospice principles. He wanted refills on donepezil, warfarin, and simvastatin—the drugs that we'd convinced them were life-sustaining. He asked me to renew Akiko's referrals to neurology and dermatology. He wondered why the physical therapist no longer came. Bob was on board © 2015 American College of Physicians 145
Downloaded From: https://annals.org/ by a Universite Laval Biblioteque User on 08/05/2017
ON BEING A DOCTOR with palliative care for the assistance but not really for terminal care. What did Akiko want? I judged her quality of life to be zero. If she were my own mother, I would provide comfort medicines only and hope for a speedy death under the care of hospice. But perhaps “dignity” to Bob meant seeking another MRI and more tests and subspecialty visits. He obviously took very good care of her, and “care” to him extended beyond creamed skin and forceful feeding. Would I rob him of that? The contrasts of old age can be stark: once competent, now totally dependent; once a servant, now in constant need. Once he trusted Western medicine to diagnose and cure, now he was skeptical as we urged him to give up. Revoking hospice might have sent Akiko back into frequent hospitalizations, expensive medicines, and unavailing subspecialty work-ups. Maintaining her on hospice meant repeated confrontations about end-of-life care. “Bob,” I said gently, with as much compassion as I could muster for that one-syllable name. The pang of wanting to do everything for him stopped my words for a moment. Cheerful and pandering until now, his face was suddenly stoic and solemn. I felt the tightness of the bento home and fleetingly compared it with my own spacious East Bench house. Old-time movies of a mushroom cloud and tiny cachectic people marching away from desolation ran through my mind. “What are a few extra medicines or specialist visits?” I asked myself. But then I remembered that Bob was not my patient, and I felt the duty and the will to help Akiko. “Bob,” I said, “you have served Akiko so well. You have fought a great battle. It's time now to let her be free.” A sigh of celebration from the nurse. Bob's stillstoic head was held high, but quickly an involuntary
Surrender
tear formed in his eye. And his visage softened to surrender. I expected anger. I expected to engage in a struggle. I thought I might even be kicked right out of the door. I did not expect resignation. “Doctor, you very good doctor, you Harvard doctor.” A tiny trembling smile showed that he had researched my name. He paused as if to judge whether I was an imposter. “I will do as you say, doctor.” He brought his hands together and gave a short bow, like a Samurai handing over his sword. I thought that the nurse might revel in “told-you-so” and spoil the moment. Instead, we all sat silently, mourning the end of life of one small but highly honored woman. I departed the same way I came, with hand clasps, head nods, and much thanks. I departed in peace, to my pleasant surprise. I did not see them again. Akiko passed just 2 weeks later. When I received the text message notifying me of her liberation, I felt no victory, only sadness for her faithful husband. I, too, put my hands together and bowed my head silently, a fellow soldier also in surrender. Richard Allen, MD, MPH Utah Healthcare Institute Salt Lake City, Utah Requests for Single Reprints: Richard Allen, MD, MPH, Utah
Healthcare Institute, 1250 East 3900 South, Suite 260, Salt Lake City, UT 84124; e-mail, [email protected]. Ann Intern Med. 2015;163:145-146. doi:10.7326/M15-0023
146 Annals of Internal Medicine • Vol. 163 No. 2 • 21 July 2015
Downloaded From: https://annals.org/ by a Universite Laval Biblioteque User on 08/05/2017
www.annals.org
