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Jonathan Gotfried

From my wife's grandparents' Manhattan apartment, I could hear the noises of traffic and pedestrians in Central Park, seven floors below. The sounds made a refreshing change from the beeping monitors, overhead pages and ringing phones that are the usual backdrop to my work as a physician in a large Philadelphia medical center. Here the only background conversations I heard were those of loved ones in the kitchen, not those of patients' family members, overheard through flimsy curtains ringing an adjacent bed.

The hospice nurse quietly moved about the apartment. My wife sat close by her grandfather, Werner (whom we called Saba, Hebrew for grandfather), speaking softly with him as he lay there in bed. Our two-year-old son sat nearby, dutifully flipping through a Dr. Seuss book, occasionally drawing my attention to a funny-looking fish or tree.

I stood at the foot of Saba's bed. My instinct, honed by my medical training, was to pull back the sheet to check the pulses in his feet. I wanted to read a chart, throw in an order, see if he needed better pain control.

What was his fluid intake for the day? I wondered, then thought, It must be getting harder for him to breathe.

Saba had been through countless rounds of chemotherapy. This had kept him alive and living for years after his initial grim prognosis of a year or less. He'd weathered radiation therapy and innumerable office visits. But now his renal-cell cancer had spread.

A decade had passed since I'd last faced the death of a family member; I was a premed college freshman at the time. I had raced home cross-country to spend the last moments with my own grandfather, Zaide (Yiddish for grandfather).

"Remember the cruise?" my grandmother had whispered in his ear, reminding him of their sixtieth-anniversary celebration aboard a Royal Caribbean liner with our extended family. Only moments after she spoke these words, he sailed away forever.

Since then, death and dying had become all too familiar to me--but in a more guarded, less personal sense. Death came buffered by white coats and stethoscopes, or by the controlled chaos of a Rapid Response or Code Blue. Emotions that threatened to become too raw were tempered by statements like "He was so sick anyway."

In Saba's apartment, the conversation was light. We spoke of a pencil drawing hanging on the wall, and of the book collection that climbed ten shelves up to the ceiling. An engineer by training, Saba loved the natural sciences--he subscribed to Science and the New England Journal of Medicine--but his erudition extended beyond the sciences to classical music, Jewish history and theology, and theater. Today, though, we talked about mundane matters--our dinner plans that night, and whether my schedule would be hard in the weeks ahead.

As my wife, son and I left the apartment, there were no goodbyes; just a simple "I hope to see you again soon." We drove down the Jersey Turnpike to Philadelphia for another week's work.

A few days later, at my outpatient clinic, I found myself across from Raul, who had been my patient for almost three years. Recently diagnosed with cancer, he was here to see me for new-onset abdominal pain. He sat staring at me and holding his swollen belly, his sunken, jaundiced eyes framed by deep, cavernous temples.

He looks so uncomfortable, I couldn't help thinking.

Earlier, seeing Raul's name on my schedule, I'd hoped to myself that someone ahead of him would cancel, so that he and I could have more time to talk. But my hopes had been frustrated: Everyone had showed up, and my "Scheduled Patients" screen was filled with the names of other patients sitting out in the waiting room.

So much for that, I thought.

START NEW PROGRESS NOTE the computer screen urged; the twenty checkboxes in the Physician Examination section of the electronic health record were unchecked. But still I stalled for time; I just couldn't make myself rush through this talk.

I kept thinking of how my own loved ones, Saba and Zaide, had been surrounded by family members during their last months and final moments. I felt that I couldn't let Raul face this journey alone.

Memories from my residency started unspooling in my mind. I'd been down this road many times before with other patients. No doubt each one had had his or her own story and family situation; each must have experienced death's approach in a uniquely personal way. But suddenly, looking back, I realized how little I knew about any of them. It struck me that I'd often left the "Social History" section of my history and physicals absurdly empty. My usual notes--"Lives with daughter" or "Retired military"--seemed almost insulting; they didn't even come close to filling the allotted two lines.

I looked at Raul, knowing that when I listened to his lungs I would hear only faint breath sounds; his chest was already heaving in an effort to draw in adequate breath. If he were to lie on the exam table, a gentle tap on his abdomen would send a wave coursing through its accumulated fluids. His heart must be racing too, overworked as it was from his hypermetabolic state. Did I really need to feel for lymph nodes or look for other signs of his encroaching malady?

After his diagnosis, Raul had told me, "Once I'm feeling better, I'd like to retire to Florida and build a boat." Recalling his words, I thought, This is the hardest part of medicine: telling a patient that his dreams will remain only dreams, never to be fulfilled.

Sounds from outside the exam room--the muffled voice of my preceptor in the adjacent exam room, an EKG machine being rolled down the hall--broke the silence. As familiar as they were, this time they felt utterly out of place.

Here and now, I wanted to give my patient Raul what I would have given Saba or Zaide in this situation.

So I reached out--but not to pick up my stethoscope or the computer mouse, or to pull the footrest out from the exam table. Instead, I put my hand on Raul's bony, sunken shoulder.

"I'm here," I said. "What can I do to help? How can we make this easier?"


About the author:

Jonathan Gotfried is a gastroenterology fellow at Temple University Hospital, in Philadelphia. He wrote this piece during his internal-medicine residency, after the passing of his grandfather-in-law, Werner Rosenbaum. "I use writing to reflect and understand the complexities, struggles and challenges of the day-to-day lives of the caregivers and patients in the world of medicine."

Story editor:

Diane Guernsey

Comments   

# KeeMac 2015-12-07 17:39
Such a lovely ending - it speaks to the feeling of helplessness and also your caring. As one with cancer myself, I would be grateful to have such a one as you there at the end. It trumps all other form of medical intervention, even if it has no category suitable for billing purposes.
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# Diane Greig 2015-11-28 19:35
Cut to the essence~ a beautiful piece. Thank you for sharing. Tucked into my memory for when I need to remember this.
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# Yehudit Reishtein 2015-11-28 12:39
What a great description of the thought processes as you confronted the problem of how to talk to Raul. You came up with the only question that could help him: "How can we make this easier?"

I hope you are able to retain this thoughtful caring approach throughout your career.
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# Marianne Lonsdale 2015-11-28 10:42
A lovely piece that I'm so glad I took the time to read. The writer captured the hospice experience so well.
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# Daniel Lang 2015-11-28 10:13
Jonathan, just an observation, for you why is the hardest part of medicine, telling a patient that his dreams will remain only dreams, never to be fulfilled. I have dreams but I realize that some will not be fulfilled. Unfulfilled dreams are a part of life, beginning or end. I worked in hemodialysis for 15 years and faced death many, many times with many folks. These people make up a fabric of my memory of this incomprehensibl e thing called life.
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# Ron Banner 2015-11-28 07:31
Shabbat Shalom, Jonathan, and Yasher Koach on this beautiful tale, with so much to teach us.

As health care professionals, we learn from many sources, including our own personal experiences. You have been blessed with your Zaide and Saba and with being able to journey with them, including at the ends of their lives.

Today's reality is that we do not visit our patients; they visit us, in our offices or clinics - so we do not get to see their libraries or pictures on their walls of family members or special places they've been.

Had your fellowship occurred 65 years ago, you would have had a superb psychosomatic program right at your school - but in today's training, EMR, guidelines, & cost-effectiven ess have replaced discovering & partnering with the unique person who is our patient.

However, being present with our patients is the cure; being a Ropheh means "How can we make this easier?"



Ron Banner MD
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# Fran Brahmi 2015-11-28 05:29
Jonathan,
You words moved me to tears as I remembered my mother's last moments and how I could not be there by her side. Thank you for writing this beautiful story.
Bless you.
Fran
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# Pam Mitchell, RN 2015-11-27 21:28
Ah Jonathan Gotfried....ble ss you. This is eloquently written with poignant reminders of the importance of this work.So often, I think, we wonder what we can do with the seemingly daunting increase of demands. You have reminded us of the power of touch, and the importance of asking. Thank you.
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# Norma Smith 2015-11-27 20:38
Thank you for choosing medicine and for choosing to care for your patients in this way. and for your writing so we can feel it.
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# Henry Schneiderman 2015-11-27 20:20
I agree with Pris Campbell: this story is at the heart of our calling, not just for palliative care personnel like myself, but for every physician, every APRN, every nurse, every PA. We much more often flounder on the humane than on the technical and bioscientific side, and Doctor Gotfried has shown the balance though this lovely reflection is the farthest thing from pedantic or preachy.
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# Pris Campbell 2015-11-27 18:00
A wonderful, compassionate story. Thank you.
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# barbara young 2015-11-27 20:38
This is one of the loveliest things I've read in a while--thank you, Dr. Gottfried for sharing it. I do wish you were teaching humane palliative care of this kind to medical students.

The old answer is, "They (students) have no time for this."
Yes, but time must be made, mustn't it? --For the future of mankind, if nothing else.

Thanks again, doctor.

Barbara
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