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A Good Death

sail boat

When I interview medical students for positions in the family medicine residency, I often ask them to tell me a story of a patient who has been meaningful to them or taught them something.  It is remarkable how often these stories have to do with death and their first or early encounters with the dying.  In our culture, we have minimal contact with death or with dying people.  Illness is so neatly sanitized away in the hospital that very few medical students have experienced a loved one’s death before they have to deal with death on a professional level.

My first encounters with death happened during that fateful surgery rotation at the Royal Victoria.  One of the surgeons on the service was Henry Shibata, a surgical oncologist.  His patients were my first encounter with the edge of life and death. 

The patient I remember most strongly was a young man of 34 years old, he had a melanoma removed some time before, and routine follow-up had revealed a strange opacity in his lungs.  He was very young, though slightly older than I was at the time. He was a tool-and-die maker.  My father believed that tool-and-die makers are the human equivalent of God as engineer and had instilled in me an admiration for such accomplishments.  My patient, whom we will call Doug, was surprised that I even knew what a tool and die maker was.  He was also amused by my evident respect for his trade.  Doug was, in other ways, pretty young.  He was also not someone whom I would usually hang out with. He was recently divorced with two small children that he was not particularly interested in.  He had a blond girlfriend in tight jeans who visited seldom and not for long.  His main passion in life was the sailboat he had built for himself and his Harley: not the usual companion for a university-educated feminist. Doug was a nice man and very frightened. He was also bored to distraction in the hospital.  Since I was in the hospital 36 hours out of every 48, we saw each other often.  Sometimes in the evening, if it was not too busy, we would play a few hands of cribbage together.  He told me about himself, his life, and his plans to go sailing.

We were doing all kinds of investigations to try and figure out whether or not these vague opacities in his lung were melanoma or not.  Dr. Shibata thought that they might have represented a side effect of chemotherapy or a strange infection.  John, the chief resident, had no such beliefs. “Got to be melanoma, he said, “It only stands to reason.”

One night I was called to admit another patient to Dr. Shibata’s service.  This was a gentleman, also with melanoma, who had begun acting strangely and erratically. The work-up had revealed that he had metastatic melanoma in his brain.  Admitting him, I saw a man who three weeks earlier had been a practicing lawyer. Now he was utterly undone by his disease.  Semi-comatose, completely confused, he lay on the bed, his fingers randomly picking at the bedclothes.  His wife was a chic well-dressed woman, haggard-looking from lack of sleep. She was reduced to red eyes and rough hair, her carefully varnished nails and cuticles all bitten.  She did not want to leave her husband’s side even though she was exhausted. “Go home,” I reassured her, “nothing will happen tonight. I’ll call you if there is any change”.  The next night I was on call. I went around the floors, checking on the patients before I went for my supper.  The patient with the brain metastases was Cheyne-Stoking. I called the patient’s wife to tell her that it would probably be tonight.  I also called in the hospital chaplain.  When I came back a little later, the whole family was at the bedside crying softly and holding each other.  Soon after the patient received the final sacrament, he died.

“You knew, didn’t you? You knew it would be tonight” The wife was looking at me with a kind of awe that made me very uncomfortable. “I want to thank you, doctor,” said the patient’s wife when all was over. “I know that you couldn’t save my husband, but you helped him to a good death.”

This was one of the first times anyone had called me Doctor, and it was the first time I didn’t flinch when they did.  I went home the next evening feeling that I had learned something important and crossed some sort of line in my training.

The next day we sent Doug for a CT and fluoroscopy of his chest.  I injected him with a sedative, and he got into his wheelchair.  Suddenly his body stiffened, and a grand mal seizure shook him.   When he recovered, they sent him down again.  This time a CT of the head was added to the requests.  The results when they came back were what John had been expecting.  In the two weeks since his previous chest x-rays, the vague opacities had turned into the classic “cannonball” lesions of melanoma in the lungs.  The same cannonballs were bombarding his brain.  Doug was done for.  Dr. Shibata went into the room to give his patient the bad news. 

Late that night, around ten o’clock, I got up to see him.  He was crying.  He cried in that gut-wrenching way that macho men do as if the act of letting the tears fall was in itself a wound. “Get me out of here,” he said, “I need to get home. I have to talk to my girlfriend and my wife; I have to see my kids and arrange things for everybody.  I want to go sailing.” I agreed to try and help him.  I counted on seeing Dr. Shibata on rounds the next morning, but it turned out he had gone away for the weekend.  I asked John how I could get a weekend pass for Doug. 

“Forget it, we’ll never be able to block the bed for three whole days, just tell him he has to stay in.” Not content with this answer, I asked the head nurse. 

“You can only do it if you get written permission from the Director of Professional Services.” She made it sound as if this was like asking for dispensation from the pope to commit murder.  I decided to try.  Dr. Sylvia Cruess was the DPS at that time, but her husband, Dr Richard Cruess, was replacing her when I called.  I had never met Dr. Cruess before, even though he was the Dean of the medical school when I was a student.  What he said to me that day inspired my profound respect.  He listened to this very junior medical student’s disjointed request to block a surgical bed for three days.  This is a sacrilege for any hospital administrator. 

“Well, I don’t think we should let a little bureaucracy prevent us from doing what’s best for this patient, should we?” He said.  Doug went home for his weekend and was very happy.  Soon after, I left the service. I visited the ward about a month and asked after Doug.  He had deteriorated quite rapidly and died a few weeks after I left the service. 

“Was it a good death?” I asked the nurses.  He had been all alone

at the end, they said.  It had been pretty bad.  That weekend I arranged had been his last weekend home.