IN A FEW WORDS
To Whom Shall I Tell My Grief?
I
Am J Kidney Dis. 2013;62(5):xxv-xxvi
degrees with altered mental status, prompting this latest hospital admission. When I went to examine the patient, she was lying still in bed, barely responsive. Her hair was braided neatly under a black wool hat and she had deep bags under her eyes. Her skin was on fire, her pulse was rapid and bounding, and she had a vesicular rash over her right torso. I called her name loudly, but she did not react. I asked her questions, and she occasionally and inconsistently murmured “yes” and “no” but did not open her eyes. I wondered if her limited ability to interact with me was a clue that her fevers were related to a central nervous system infection. As I examined her more, however, I sensed that her decreased responsiveness was volitional—a passive protest against my poking and prodding. I asked her, “Am I annoying you with my questions and exam?” With her eyes closed, she gave her most definitive answer of the day: “Yes!” Her son, who was also in the room, chuckled when he heard her say this. He was a stocky middle-aged man, wearing a gold cross and a baseball hat. We exchanged introductions, and I asked him to tell me about his mother’s medical problems. At first he was angry and accusatory, recounting his mother’s multiple hospitalizations and the many failings of the medical teams who took care of her. He warned me not to give her antibiotics, because they had done “nothing” to help her in the past. After a few minutes, he calmed, and started to tell me about what his mom was like before she was on dialysis. She grew up in the South, 1
Chekhov A. Misery. http://www.eldritchpress.org/ac/jr/ 045.htm. Accessed October 1, 2012. [Garnett C, Trans.; original work published 1886] xxv
IN A FEW WORDS
n his short story “Misery,” Anton Chekhov tells the tale of a sledge-driver named Iona, who has recently learned that his son is dead. Late on a frigid St. Petersburg evening, Iona struggles to push through the final hours of work, although he is distracted by his sadness. He tries to engage his drunk and rowdy passengers in a discussion about his son, but they dismiss his concerns and berate him. One of his fellow drivers similarly shows no emotion, offers no condolences. At the end of his shift, Iona leads his horse to the barn, and in his desperation, he starts to tell his horse the details of his son’s death. The final lines of the story are the most gripping: “The little mare munches, listens, and breathes on her master’s hands. Iona is carried away and tells her all about it.”1 I was reminded of this story on a chilly spring weekend in Boston, when I was covering the infectious diseases consult service for the day. I felt at once anxious about the potential for a busy day and calmed by the still and quiet of the hospital. One of the interns paged me to say a “very complex” patient was being admitted from hemodialysis for fevers. Reviewing her chart, I learned that she received a kidney transplant in the early 1970s, and she had done well for more than 30 years before her transplant failed and she began dialysis again. In the past 2 years she had been in the hospital more than 10 times with serious medical issues, including cardiac tamponade, perforated diverticulitis, and vertebral osteomyelitis. Following an extended course of antibiotics, she continued to have spiking fevers, night sweats, and weight loss, and a very thorough work-up had yet to reveal the source. In dialysis she was noted to be febrile to 103
IN A FEW WORDS
Alysse G. Wurcel
raised her son as a single mother, and worked several jobs at one time. She had always been an incredibly independent woman. Dialysis, in his opinion, was draining her of her life and the only way she could be saved was by getting a new kidney. The nephrologists told him that with all of her infections, she was too sick to get a kidney right now. “I’m a match, you know,” he added quietly. He had been tested more than 5 years ago and told that if he wanted to donate a kidney to his mother, he would have to lose weight. He had tried, but there were no healthy food options where he worked, and he had no time to exercise. His weight had stubbornly remained over the level considered acceptable for donation. “I love her so much, and I want her to get better. What do you think? Do you think that she would do okay with my kidney? Should I give her my kidney?” I thought about the infectious risks, and the potential complications, and the side effects of medications. His mother’s candidacy for transplantation seemed a dim and distant prospect, given everything I had learned about her in the last hour. His candidacy for donation seemed similarly dim, given his weight issues. Then I realized that none of these medical details were pertinent to his question. The roots of his question lay deeply embedded in his childhood experience, his relationship with his mother, and his personal hopes and dreams. There was
no correct answer. I wished I could just sit there and be the warm body to absorb his thoughts and words without the expectation of a reaction. Like the horse in Chekhov’s story, I wanted to be able to offer comfort by simply being there. I was shocked that his words flowed so freely, as if he had not had anyone else to talk to about this very difficult decision. I was touched at how much he had revealed to me, a stranger taking care of his mother. I do not think it is a coincidence that Chekhov, the author of my favorite short story, was also a physician. I think he understood that in times of sickness and death, people need to talk and doctors need to listen. It felt like 10 minutes passed before I found the words. “I don’t know what the right answer is,” I said, quietly. “You don’t need to make any decisions today. Your mom is just lucky to have a son like you.” Alysse G. Wurcel, MD Boston, Massachusetts I would like to thank the patient and her family, for inspiring this piece and providing feedback. Thanks to Peaches Udoma for motivation and editing. Dr Wurcel is an Infectious Disease fellow at Tufts Medical Center. Address for correspondence: [email protected] © 2013 by the National Kidney Foundation, Inc. 0272-6386/$36.00 http://dx.doi.org/10.1053/j.ajkd.2013.08.006
ⴖIN A FEW WORDSⴖ PODCASTS Listen to podcasts of selected contributions from the ⬙In a Few Words⬙ series! Podcasts are freely available at http://ajkd.org/content/podcast and the AJKD podcast page at the iTunes Music Store (http://bit.ly/nBKqAb).
xxvi
Am J Kidney Dis. 2013;62(5):xxv-xxvi
To Whom Shall I Tell My Grief?
I
Am J Kidney Dis. 2013;62(5):xxv-xxvi
degrees with altered mental status, prompting this latest hospital admission. When I went to examine the patient, she was lying still in bed, barely responsive. Her hair was braided neatly under a black wool hat and she had deep bags under her eyes. Her skin was on fire, her pulse was rapid and bounding, and she had a vesicular rash over her right torso. I called her name loudly, but she did not react. I asked her questions, and she occasionally and inconsistently murmured “yes” and “no” but did not open her eyes. I wondered if her limited ability to interact with me was a clue that her fevers were related to a central nervous system infection. As I examined her more, however, I sensed that her decreased responsiveness was volitional—a passive protest against my poking and prodding. I asked her, “Am I annoying you with my questions and exam?” With her eyes closed, she gave her most definitive answer of the day: “Yes!” Her son, who was also in the room, chuckled when he heard her say this. He was a stocky middle-aged man, wearing a gold cross and a baseball hat. We exchanged introductions, and I asked him to tell me about his mother’s medical problems. At first he was angry and accusatory, recounting his mother’s multiple hospitalizations and the many failings of the medical teams who took care of her. He warned me not to give her antibiotics, because they had done “nothing” to help her in the past. After a few minutes, he calmed, and started to tell me about what his mom was like before she was on dialysis. She grew up in the South, 1
Chekhov A. Misery. http://www.eldritchpress.org/ac/jr/ 045.htm. Accessed October 1, 2012. [Garnett C, Trans.; original work published 1886] xxv
IN A FEW WORDS
n his short story “Misery,” Anton Chekhov tells the tale of a sledge-driver named Iona, who has recently learned that his son is dead. Late on a frigid St. Petersburg evening, Iona struggles to push through the final hours of work, although he is distracted by his sadness. He tries to engage his drunk and rowdy passengers in a discussion about his son, but they dismiss his concerns and berate him. One of his fellow drivers similarly shows no emotion, offers no condolences. At the end of his shift, Iona leads his horse to the barn, and in his desperation, he starts to tell his horse the details of his son’s death. The final lines of the story are the most gripping: “The little mare munches, listens, and breathes on her master’s hands. Iona is carried away and tells her all about it.”1 I was reminded of this story on a chilly spring weekend in Boston, when I was covering the infectious diseases consult service for the day. I felt at once anxious about the potential for a busy day and calmed by the still and quiet of the hospital. One of the interns paged me to say a “very complex” patient was being admitted from hemodialysis for fevers. Reviewing her chart, I learned that she received a kidney transplant in the early 1970s, and she had done well for more than 30 years before her transplant failed and she began dialysis again. In the past 2 years she had been in the hospital more than 10 times with serious medical issues, including cardiac tamponade, perforated diverticulitis, and vertebral osteomyelitis. Following an extended course of antibiotics, she continued to have spiking fevers, night sweats, and weight loss, and a very thorough work-up had yet to reveal the source. In dialysis she was noted to be febrile to 103
IN A FEW WORDS
Alysse G. Wurcel
raised her son as a single mother, and worked several jobs at one time. She had always been an incredibly independent woman. Dialysis, in his opinion, was draining her of her life and the only way she could be saved was by getting a new kidney. The nephrologists told him that with all of her infections, she was too sick to get a kidney right now. “I’m a match, you know,” he added quietly. He had been tested more than 5 years ago and told that if he wanted to donate a kidney to his mother, he would have to lose weight. He had tried, but there were no healthy food options where he worked, and he had no time to exercise. His weight had stubbornly remained over the level considered acceptable for donation. “I love her so much, and I want her to get better. What do you think? Do you think that she would do okay with my kidney? Should I give her my kidney?” I thought about the infectious risks, and the potential complications, and the side effects of medications. His mother’s candidacy for transplantation seemed a dim and distant prospect, given everything I had learned about her in the last hour. His candidacy for donation seemed similarly dim, given his weight issues. Then I realized that none of these medical details were pertinent to his question. The roots of his question lay deeply embedded in his childhood experience, his relationship with his mother, and his personal hopes and dreams. There was
no correct answer. I wished I could just sit there and be the warm body to absorb his thoughts and words without the expectation of a reaction. Like the horse in Chekhov’s story, I wanted to be able to offer comfort by simply being there. I was shocked that his words flowed so freely, as if he had not had anyone else to talk to about this very difficult decision. I was touched at how much he had revealed to me, a stranger taking care of his mother. I do not think it is a coincidence that Chekhov, the author of my favorite short story, was also a physician. I think he understood that in times of sickness and death, people need to talk and doctors need to listen. It felt like 10 minutes passed before I found the words. “I don’t know what the right answer is,” I said, quietly. “You don’t need to make any decisions today. Your mom is just lucky to have a son like you.” Alysse G. Wurcel, MD Boston, Massachusetts I would like to thank the patient and her family, for inspiring this piece and providing feedback. Thanks to Peaches Udoma for motivation and editing. Dr Wurcel is an Infectious Disease fellow at Tufts Medical Center. Address for correspondence: [email protected] © 2013 by the National Kidney Foundation, Inc. 0272-6386/$36.00 http://dx.doi.org/10.1053/j.ajkd.2013.08.006
ⴖIN A FEW WORDSⴖ PODCASTS Listen to podcasts of selected contributions from the ⬙In a Few Words⬙ series! Podcasts are freely available at http://ajkd.org/content/podcast and the AJKD podcast page at the iTunes Music Store (http://bit.ly/nBKqAb).
xxvi
Am J Kidney Dis. 2013;62(5):xxv-xxvi
