“Which is more beautiful, feline movement or feline stillness?”
ELIZABETH HAMILTON
“DAVID, CAN YOU STOP BY? I DON’T LIKE THE WAY SAUL looks. I think he’s becoming septic.”
It was Mary, and she had reached me on my cell phone as I headed to the university for a research meeting with several colleagues. One of the many things I liked about Mary was that she did not overreact. If she said a patient looked bad, I changed whatever course I had set for myself and headed for Steere House, as I did that warm spring afternoon. The meeting would have to wait.
As I entered the unit I was greeted by a tall, well-dressed man who was standing near the nurse’s station, deep in discussion with Mary. Even with his back toward me I knew that we had met before. I think it was his accent.
I rounded the desk and acknowledged the pair with a quick hello as I pulled Saul’s chart off the rack with the urgency Mary’s phone call had instilled. I rifled through the pages for his recent labs and kept one ear tuned to the conversation unfolding in front of me.
“Mary, my mother’s going to be much better off in the hospital,” the man said.
Now I remembered. I had met him in the hospital months ago when his mother, Iris Duncan, had been admitted with pneumonia. There had been nothing extraordinary about her admission, and she had rebounded rather quickly, but I had spent considerable time talking with her son about his mother’s care and her declining condition.
He was full of questions, which was to be expected. His mother had a serious disease that was progressing and anyone would have been looking for answers. But the tenor of our conversations suggested to me that he had not yet come to grips with the terminal nature of his mother’s condition. He seemed to be in a state of constant negotiation. “What if we try this, Doctor?” he would ask, invoking some medicine or procedure he had heard of or read about on the Web. When I had explained why one tactic wouldn’t work, he had been quick to suggest another. Listening to him now, I could tell that nothing had changed.
“George,” Mary was saying, “your mother’s really not doing well. I think she’s got another bout of pneumonia brewing and with the infection she’s more confused than ever. Are you sure you want us to send her over to the hospital again? You know, we can treat her with antibiotics here in the nursing home where we all know her and she’s comfortable with her surroundings.”
The offer sounded reasonable and for a moment George seemed to waver from his initial insistence that his mother be rushed to the hospital. Maybe he could be persuaded that keeping his mother in the nursing home would be in her best interest.
He turned to me.
“It’s Dr. Dosa, right?”
“How are you, George?” I was glad to have overheard Mary using his name.
“It’s good to see you again. Will you be taking care of my mother when she goes to the hospital?”
I shook my head no. “One of my other colleagues is covering the hospital this week. But I do know your mother, George, and I agree with Mary that her dementia is getting worse. She’s usually out here, sitting by the desk—and she’s always been quick with her hellos in that delightful accent of hers. Lately, though, I haven’t seen that same resilience. If you like, I can give your mother’s doctor a call. I think treating her here would be in her best interest.”
But his mind was made up. As George walked away, Mary turned to me.
“How do you know George?”
“We met a few months back when his mother was in the hospital. I think we talked for almost an hour on one occasion. He had so many questions about his mother’s care. He literally wanted to know everything.”
Mary laughed. “He’s very involved. Even when he’s traveling for his job, I get phone calls from him every day: ‘How’s my mother doing? Is she eating? Resting okay?’” She sighed. “Though, honestly, I hope that when it’s my time, one of my kids will be as involved with my care as George is with his mother’s.”
“I tried to talk to him about hospice for his mother before,” I said. “Did they ever get involved?”
“He’s nowhere near ready for that, David.”
But she may be, I thought. “What’s her condition now?” I asked.
“Same as before. The X-ray says she’s got pneumonia again, and she’s confused.”
“Has Oscar been by?”
Mary laughed. “Of all the patients on the floor, Oscar probably hides from her the most. She’s always chasing him. Half the time, she tries to pull his tail. I’m not sure Oscar’s going to want to be there when she goes.”
“Is she still full code?” I wanted to know whether or not we would conduct CPR if her heart or breathing ceased.
“Uh-huh.”
“I remember the first time I met her in the hospital,” I said. “Even when she was ill, she was so vibrant!” Her smile could light up a room, but she had deteriorated since then.
“There are times when I still can’t believe what this disease does to people,” Mary said. Her thoughts must have been running on a similar track. “I think Iris has actually been at Steere House longer than I have. When she was first admitted to the dementia unit downstairs, people used to confuse her for one of the staff. She was such an educated, articulate woman. I think Columbia University actually gave her a college scholarship to come there from St. Kitts.”
“So that’s where the accent is from!”
“When I first met Iris, she was actually tutoring some of our aides downstairs on their English,” Mary continued. “She was also an ordained minister, and I remember hearing her talk to at least one aide about her faith.”
Mary smiled at the memory. “I always thought it was funny that she could still teach English and recite the Bible, chapter and verse, despite her condition. You never lose those teaching skills, I guess.”
“But you called me about Saul,” I reminded her.
“He may very well be the second hospital admission today,” she said. “Go take a look at him and see what you think. You’ll find Barbara there. She’s very concerned.” With that Mary turned toward her office, a copy of Iris Duncan’s chart in her hands. As I left she was calling the medics to bring her to the hospital.
ONE LOOK AT SAUL and I understood Mary’s concern. He was in bed rather than his recliner. The television was off and there was no life in his eyes; he seemed unable to keep them open for even a few seconds. His daughter was seated at the bedside, holding his hand.
“How’s he doing?” I asked.
Barbara stood up and looked at me. I could see the worry in her face. “Not well, Doctor. Mary called me in to see him.”
She stood aside to allow me to examine her father. I measured his blood pressure and confirmed that it was low. I felt his thready pulse and listened to his lungs. As I examined his legs, it was obvious where the infection was coming from. They were red and swollen. An area near his shin was openly weeping, a result of cellular fluid being pushed to the surface from damaged cells.
“He’s pretty sick, Barbara. I think he may be septic, a condition where the bacteria in his leg have gotten into his blood.”
She nodded but said nothing.
“You know, I don’t think we can handle this degree of illness over here. We’re going to have to make a decision about whether to hospitalize him.”
“Whatever you think, Doctor.” This did not sound like the woman who had always been so resistant to the idea of not treating her dad. I decided to use this opening to revisit his end-of-life wishes.
“Barbara, I know when your father was first admitted, you had requested that we do everything in our power to restart his heart if it stops. I’d like to talk about that if we could.”
“Well, if you can save him, I think you should try.”
“You know, it’s not like it is on TV.”
She gave me an odd look and I felt like I was in danger of crossing a line but persevered.
“On television, they always get everyone back,” I said. “It’s not like that in real life.”
“I know that,” she said rather coolly.
“In cases like your father’s, where someone has a chronic medical illness like dementia, we’re very rarely able to get someone back if their heart or breathing stops. On television, patients almost always survive. In reality, based on your father’s age and his medical problems, I very much doubt we’d ever get him out of the intensive care unit.”
“Why wouldn’t we do everything in our power to save him?” Now there was heat in her voice.
“Sometimes, when patients are really ill, all we are doing is postponing the inevitable and inflicting more pain. Regardless of whether we fix his infection, he’ll still have the dementia. We could always keep him here and make him comfortable.”
Barbara looked at me with anger.
“Doctor, my father wanted everything done to keep him alive. Even if there’s the smallest chance that he can recover, I think he would want that. I’m not going to change his wishes now.”
I wasn’t surprised by her response. I was a traveling salesman pitching an unpopular product: the reality check. I considered reminding her that her father’s circumstances had changed, but I resisted the temptation. It wasn’t going to change anything.
“Doctor, I don’t want to talk about any of this right now. My father needs medical attention and we need to get him to the hospital immediately.”
I left the room to start making preparations for Saul’s transfer. As I sat at the desk staring off into space, thinking about all that had just transpired, a visitor appeared from out of nowhere. Walking along the length of the front desk, Oscar came toward me and sat down next to the telephone. His eyes fixed on me.
“Why don’t you go talk to Barbara, Oscar? Maybe you can convince her.”
He looked at me and for a second I imagined that he was considering my request—as if a cat would do what you wanted even if he could understand you. Instead he rolled on his belly in front of me in an invitation to scratch him. I reached over and paid my due diligence as he began to purr.
“You’re really just a cat, aren’t you?”