5.13.2009

On Death

Sorry, it's a long one...

My first patient was a gaunt and scruffy man in his fifties. Six medical students and three physicians crowded into his hospital room. We watched as one of our preceptors demonstrated the patient interview, asking the open-ended questions we would learn to emulate, expressing empathy, finding points of connection to this man’s life. He answered each with an affect so flat he seemed less than human. A nearly imperceptible moment of anger, a half smile to acknowledge enthusiasm for the Sox, these were the windows into his emotional life. The medical details of his case hardly mattered, advanced cancer, failures of compliance. After the interview we speculated on his personality, his attitude around his illness, the effectiveness of the interview strategy. And that night I summarized him into three boxes, chief complaint, history of present illness, and the more amorphous “patient as a person,” a place holder for more boxes to come. A few weeks later, debating the relative utility of silent pauses, clarifying language or casual posture that first interview came up again. As the conversation turned, our preceptor said casually, “He died, by the way.”
Months later, an unusual afternoon left me alone in for over an hour with a vibrant woman in her eighties. If one thing has become clear, it is that all lives that long carry some burden of personal tragedy. She spoke with zest, and a warmth that conveyed gratitude, about her work as an artist. She countered each mention of her illness with the assertion that she had lived a full life, that she had been lucky. When she stated that she would be dying, “maybe not the day after tomorrow, but three days, I think,” it was matter-of-fact. She seemed the picture of a perfect death, beyond denial, grateful for a life well lived. Two weeks later, I saw her again, being wheeled by slowly in the hallway. I greeted her, smiling to this women I now felt I knew so well. She had further thinned and paled. She did not acknowledge me, her eyes focused somewhere beyond the tangibles around us. Then again I saw her, still not dead, two weeks after that being taken from the lobby. This time I made no effort to say hello. She clutched at the thin blanket gathered around her legs, somehow appearing wholly gathered into herself.
“You can’t ask a person that when they’re dying.” He said in response to only my second question: “How are you coping?” My first, the standard “What brought you to the hospital?” he had answered with: “Well, I’m dying.” This was only a few weeks ago. I put my pen and notepad away. It is obvious that no one life, or “history” as we like to call it, can fit into the neatly categorized summary we have learned to create. But he in particular seemed uninterested in leading me through any discussion that would translate to a standard write-up. I have started interviews with patients who did not want to talk to me, and seen others do the same. These end fairly quickly and we move on to someone more willing. But this fellow resisted my questions, but not my presence. He was quick both to anger and apology. “How can you ask me about my family?” he would ask. “You do right all your life and then out of no where… how did I deserve this?” And then, “I’m being rude. I know. I shouldn’t be rude.”
Death may have much more to do with why I am in medical school than life. Not for the heroism that apparently medical students as a group tend to misperceive as their destiny, but for the experience. The sheer, visceral stimulus of standing nearby death. Yes, I hope to be part of keeping those not ready from the edge. Maybe it is our overly virtual existence or a sheltered first-world life, but there seemed to me to be something about death coming home. I saw it as a great and palpable event, the one thing that can fully remind us that we are alive.
And yet, death has not been what it seemed. Even to death, I begin to apply one-word labels. My first patient: denial. The second I mentioned: acceptance. The third: anger. But how could it be that that first petite, dull-faced man could both ignore the inevitable and then pass so casually? His death merited a mention but no fanfare. Looking back at my notes from this first interview it is barely noted that his cancer “was now considered terminal.” Here it was, September 18th, and I had already become steeled against even noticing that the person in front of me was actually going to die. I am no weak chicken. I don’t think that I needed to put up an emotional wall against such reality. And I don’t that’s necessarily what was happening either. I think I just didn’t know what death might look like. My grandfather died when I was sixteen. We were very close and my tight-knit family responded only as our irreverent selves could. We cried, laughed, hugged each other and found ways to remember. Anger and outright denial, while not a response I’ve experienced personally, still seem to me emotions fitting for the profound nature of death. And so from this first man I learned that death can be profound but it can also be blasé. That this man’s life, while it surely mattered greatly to him and to others, had reached a point where it did not need to matter to me.
My second patient seemed at first to be the picture of a respectable death, a life well lived. She expressed messy regrets that humanized her so completely. On what she named her deathbed she related to me her life story, her medical history only an aside. I felt a real connection with her. But she was not dying, not imminently. Her physician in the hallway suggested that she had months if not years, not days. I still don’t know what this can mean. The common knowledge is that people know themselves, that like cats who supposedly find somewhere warm to curl up when their time has come, the elderly make peace and bed down. Did her seeming readiness to go and surety that death was near make her suicidal? Certainly not, but what was it? And what could be the meaning of her blankness in the next weeks? Perhaps she and her physician were both wrong, and I just can’t know what she is really experiencing.
The angry man was the first patient who came close to my expected experience. While he began the interview with mostly quiet two-word responses, his anger showed through and became increasingly more articulate. And finally he turned the tables: “How would you deal with this situation?” I dodged and returned the question to him, but he called me out and threw it back. I still dodged, saying what I do now know, that “death is different for everyone.” And then, “how can I know what it will be like before I am there?” But what I really wanted to say to, and perhaps could have albeit stated more carefully was this, “I would be a hell of a lot better at this than you are. I would do what I could with the time I had left.” And that would be true, even with the details of his story that render his anger so justified. I would be inspirational, but now I’m not so sure that I wouldn’t also be full of it.
When he first told me I could not ask my questions of a man on his deathbed, I was not nervous or uneasy or excited. I was interested. I would have spoken with him for hours. I never wrote-up that interview. I never asked for his HPI beyond “cancer.” I don’t know what CC brought him in that week. The details on his social history are sketchy and tragic. He brought home to me that there are so very many things that I do not yet and cannot yet know about myself. He showed me that try as I might, there are also many things that I will not understand about others. But he did not ask me to leave, and I left his room with the clear sense that it still makes sense to try.