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I first met Bruno 15 years ago when I opened my practice. He was a 62-year-old university professor, married with two children. He was a gruff man, but with a quick smile and a penchant for telling jokes. He was an unapologetic chain-smoker, inhaling three packs a day. Bruno also enjoyed his single malt scotch neat, presented in a crystal tumbler. He had coarse facial features and was ever-ready to give his opinion on any subject, always eloquently executed in his thick European accent. His wife, Andrika, worried incessantly about Bruno’s health. She always prepared a list of Bruno’s symptoms before he came to see me. Bruno lovingly referred to her as his “house doctor,„ although she was not a physician. His daughter, however, was a physician – a subspecialist who had trained in the United States and subsequently became chief of department there. Bruno’s son had followed his father’s footsteps and was also on the faculty at the same university. Both children were very close to their parents and visited frequently.

Over time, Bruno developed a number of serious medical problems. The first was type 2 diabetes. Despite the diagnosis, Bruno remained unfazed. He was put on medications to control his blood sugar, but he made no attempt to change his lifestyle. Bruno continued to chain-smoke and did not lose weight or change his diet, much to his wife’s and daughter’s consternation. As our relationship evolved, his jokes became racier, which I interpreted as him being more comfortable with me.

It was only after developing angina that Bruno felt motivated to change his habits. With herculean effort, he quit smoking. Unfortunately, his angina worsened, and a coronary artery bypass graft was required. He did very well post-operatively and was able to enjoy his retirement and relish his reading. However, the greatest of Bruno’s passions was writing, and as such, he embarked on the composition of his ninth book.

Then, Bruno developed kidney stones. He had a complicated course, eventually requiring stone fragmentation in a tertiary care center. During a recurrence of an episode of renal colic, investigations showed incidental enlargement of the retroperitoneal lymph nodes.

There was a delay in establishing the cause of the enlarged nodes, as the subsequent scans and needle biopsy failed to demonstrate the etiology. Meanwhile, Bruno began to suffer from weight loss, fatigue, malaise and back pain. Frustrated with waiting for further tests, Bruno’s daughter arranged for him to fly to her hospital in the United States, where he had multiple scans and a repeat biopsy, which demonstrated metastatic cancer of the lung.

Upon his return from the United States, Bruno began chemotherapy. Although the prognosis for him was poor, the family insisted on treating him as aggressively as possible to extend his life. They were afraid to let him go. How could the fire and passion of this stellar man be allowed to fade and die?

The first two rounds of chemotherapy went poorly. The first resulted in hospitalization for a fever, the second in hospitalization for a diverticular abscess requiring surgical drainage. After these two rounds, I met with Bruno and his wife in my office. They sat solemnly together.

“I just don’t understand why things aren’t going well. He is strong, he came through his bypass with flying colors,„ Andrika vented, the frustration audible in her tremulous voice. “There must be another way to slow down the cancer,„ she pleaded in desperation.

Andrika sobbed openly. She wasn’t ready to give up, despite knowing that Bruno spoke the truth. He held her in silence. When they were ready, we explored together what Bruno valued, and what he wished for during the remainder of his life. “I want to continue writing my book. That damn chemo zapped all of my energy and concentration. I couldn’t focus. I want to go home and be with my family.„ He paused. “I want to write while I still can.„ To that point in his care, Bruno had let his wife and daughter determine his treatment course. Things had changed. With her face blotchy from tears, Andrika solemnly agreed to her husband’s wishes. Arrangements were made for palliation at home, and Bruno resumed working on his book.

The last time I saw Bruno was during a house call. He told me another joke. His wife and I had heard this one before, but we all laughed heartily nonetheless, particularly as Bruno delighted so much in the telling of the joke. We reflected on his remarkable life history, his many academic accomplishments and the passion that he held for his work. Although he did not subscribe to any organized religion, Bruno believed he had lived by certai n

principles, which he was proud to have followed. He valued honesty, respect and integrity – all of which personified his life. Bruno was proud of the many milestones he attained during his career, but he derived most of his fulfillment in his loving marriage and his children’s achievements.

Bruno’s only regret was that he was too weak to finish writing the very last chapter of his book. We discussed this and had a similar viewpoint – that one would want to live life such that there would always be something not quite done, something one was still wishing to accomplish.

Despite Bruno’s daughter’s earlier disillusionment with her father’s care, she came to understand that what her father needed and yearned for was an advocate who heard his heart’s desires, understood his losses and actively cared to the end. In essence, a physician, or more accurately, a therapeutic relationship, that empowered him and re-established his control over the suffering. I, as his family physician, assumed the role of advocate and facilitated communication between Bruno and his family. In the end, I was powerless at healing Bruno’s body but was able to foster an emotional healing more powerful, one that made Bruno whole again. Bruno’s losses were restored, which enabled him to reconnect with the passions that had driven his life and eased his dying.

I will always remember Bruno. He had lived life with unrestrained enthusiasm and energy. I admired his sharp intellect and the unwavering principles that guided his life. And I will miss his jokes, and his love of telling them. They remarkably served as the bond that sealed our patient-doctor relationship.