What About Bob?
The time: early one morning, thirty years ago.
The place: my local hospital.
At this point, I have been an internist for twenty years. I've just entered the cardiac care unit, where my patient Bob, a ninety-five-year-old man with advanced senility, has been brought because he's having chest pain.
As I step through the door, Bob codes. The young residents and staff swing into action, rushing the crash cart over to his bed.
Quickly, I jump between them and Bob.
"Don't resuscitate him!" I shout.
Looking stunned, they eye me as I stand there with folded arms, making myself into a human shield.
Bob lies motionless, not breathing, his monitor registering occasional spontaneous heartbeats.
Suddenly it hits me: I need to see the situation through these young residents' eyes. After all, isn't this a patient in the cardiac care unit? Aren't his monitors signaling a heartbeat? And isn't their duty to protect life?
To help them understand why I've staged this aggressive assault on their training in high-tech medicine, I must help them to understand Bob. They need to know this gentle, introverted, lonely man's story.
I look around at the residents and staff. The nurses look somewhat quizzical and maybe a bit relieved. If they were in charge, I wonder, would they have adopted a "slow code"--going through the motions at a pace that would allow nature to run its course?
"Bob and his wife were my patients for many years," I start. "Time and again he'd call me, always with the same message: 'My wife is sick, when will you come over?' Meanwhile, I'd be sitting there silently at the other end of the line, thinking, 'Not again!'
"Bob would reel off an endless list of psychosomatic complaints, and finally I'd decide that this time it might be a life-threatening condition, not just her hypochondria. I'd tell him I was on my way."
Visits to Bob's house had their own peculiar quality. Greeting me at the door, Bob always looked the same. All of five feet tall, he was a self-made banker--well-mannered, unassuming and impeccably dressed in a three-piece suit and striped tie. His expression was stern and unreadable, but over time I'd learned that it hid a deep concern for his wife. Glancing across their cavernous living room toward the bedroom, I'd glimpse their doll collection--dozens of four-foot-high figures clad in Victorian dresses, standing here and there. The place was like a wax museum; it had a haunted, lifeless feeling.
Bob would sit patiently, arms crossed, while I examined his wife. In stark contrast to her husband, she was six feet tall, brusque, demanding and needy. After finding no evidence of serious physical illness, and reassuring her as best I could, I'd take Bob aside and try yet again to explain to him that his wife seemed to have a complex case of hypochondriasis.
"He would just stiffen and stare at me," I tell the residents. "He was hell-bent on protecting his wife from any seeming dismissiveness on my part. Then he would bid me good day."
It was clear that Bob's wife was his raison d'etre--his central, maybe his only, emotional attachment in the world. It wasn't too much to say that she was his world. Given her thorny personality, I found Bob's devotion touching--even heroic.
As I stand there, telling Bob's story, my eye catches the monitor,
still recording an occasional but persistent hearbeat...
"Bob's wife died in her late eighties, of simple old age," I continue. "Bob was devastated--he had no other relatives or friends; he was completely alone. His life unraveled. He began losing his memory. Eventually he needed to be placed in a nursing home, where I cared for him. He kept wearing his three-piece suits and striped ties, but as his senility advanced, he just sat there, expressionless, lacking any desire to socialize."
As I tell Bob's story, my eye catches the monitor, still recording an occasional but persistent heartbeat. I fantasize that these are funeral drumbeats, keeping time as Bob's casket, borne in a horse-drawn carriage, bears this silent hero on his final journey.
"If you save him, his future will only hold more physical and mental deterioration," I say to the residents and nurses. Their faces have relaxed somewhat, but still hold a trace of bewilderment.
Bob passed on gracefully, spared the indignity of bodily trauma in his last moments.
Afterwards, when I'd speak with the residents about this episode, they would generally express approval of what I'd done.
Now, looking back on this confrontation that took place so many years ago, I know why I felt compelled to tell them Bob's story: it was the kind of personal, patient-centered narrative that I saw being pushed aside by the forces that were making medical caregiving ever more technology-driven and less humane.
Three decades later, these pressures have only intensified.
Ought we to take time to tell these stories to the next generation of doctors? I believe that we must. If we do not tell our stories, we all--patients and doctors alike--will become prisoners of a technological imperative that is indifferent and impervious to our humanity.
While doctors must respect and make the best use of medical technology's advances, we must also have the courage, when necessary, to challenge conventional medical care--to venture to its margins in order to preserve its heart, the relationship between patient and caregiver that is the core of healing.
About the author:
Joseph Fennelly is an attending physician in the department of medicine at Morristown Medical Center, NJ, and an instructor in medicine at Mount Sinai Medical School in New York City. He chairs the bioethics committee of the Medical Society of New Jersey. He was asked by Joseph and Julia Quinlan to care for Karen Ann Quinlan after the New Jersey Supreme Court gave medical decision-making to her father. "By virtue of my deep relationships with my patients, I've had the honor to be asked to present dozens of eulogies in which the final illness narrative deepens an understanding of the patient's life story. The mutual wound of loss can, through story-telling, lead to a mutual healing."