This is a story of two deaths. That these patients’ stories intersected on the same morning, in the same building, in two adjacent rooms, has left me thinking about them now that the day is almost done.
I was surprised to see Mrs. Stevens’ name on my schedule today. She came to the office last week, and I felt sure that she’d be too weak for another visit. But I was glad she’d made it, as I’ve become quite fond of her.
She’s seventy, and dying of metastatic lung cancer. She’s a lifelong smoker, but at this point I’m not worried about cause and effect, accountability and responsibility. None of that changes what I must do now as her physician.
A recent PET scan shows that her lung cancer has spread to her skull and spine. She has only weeks to live. She knows this, because I’ve previously told her so.
At last week’s visit, I asked what kind of care she wished to receive during her final months, weeks and hours.
“All that matters is that I make it until July,” she answered. “That’s when my grandson will come home for a visit. He’s a soldier, stationed in Texas.”
“Too far off,” I said. Even as I spoke, I cringed at how blunt, even cold, it sounded. But I’ve known Mrs. Stevens a long time, and I believe that she appreciates my straight talk and knows that I care about her.
Delicately, I suggested that buried within the black cloak of her terminal illness was a small gift: the opportunity to spend her last few weeks with intention. Surrounded by family and friends, she would have the chance to say things she may not have thought to say out loud before. She’d have the time to see, feel and hear things in a way that the “living” often do not. She could wipe her thoughts clear of the clutter that infects our minds and causes pain and unhappiness. Just maybe, these last few weeks could be an incredibly special gift to her and her family–a chance to be more present than she’d ever been before.
That was last week. This week, I knew, hospice nurses were scheduled to make their first home visit. Now here she was in my office again, along with her daughter and grandson.
“I’m surprised to see you,” I said.
“I thought it would be the last time I could make it, and I wanted to see you once more,” she replied. “My family and I are going home to celebrate.”
Her eyes sparkled. Despite her cachexia, bald head and baggy clothes, she glowed and radiated joy. I thanked her for sharing her life and death with me, and for the time that we’d had together. At the end of our visit, I hugged her goodbye, knowing it was my last chance to do so.
Routines being what they are, I moved right on into the next room. Here sat healthy, fifty-year-old Mrs. Drake, curled into a smaller version of her usual self and dabbing her eyes with a tissue.
“What’s the matter?” I asked.
“My cat died last week,” she sobbed.
Normally I’m not a pet person, and I often feel annoyed at the time and money that people lavish on their pets. But, with my reactions softened by my encounter with Mrs. Stevens, I stayed calm and asked Mrs. Drake to tell me about it.
“My cat died last week. I had her for three years, since she was a kitten. She was the only family I had,” she said. “My kids don’t speak to me, and the rest of my family is dead or uninvolved in my life. I know it seems stupid–it’s only a cat. But I don’t have anyone else!”
She went on to tell the story of how her children had stopped speaking to her. I suspected that her own mental-health issues had played a role in this, but as she described her children’s drug and alcohol abuse, and their self-created messed-up lives, I could see how these too had helped to tear the family apart. She was truly alone, and painfully aware of it.
Her visit reminded me of how many lost souls I see every day–individuals living in a social isolation for which there is no medication. They come into my office, and I treat their respiratory infections, wounds, chronic diabetes and heart disease. I convince myself that I’m doing good, helping them with their ailments. But when they return home, they again face that oldest of human conditions, loneliness.
I felt moved by Mrs. Drake’s story and her deep sadness. As I left, I bent down and gave her a hug. It was the only medicine I had for her.
“Perhaps you’ll know when you’re ready to get another pet?” I suggested.
“Yes,” she replied flatly, but with a small smile on her lips.
Now, driving home, I weigh these two stories of death and loss. Their proximity was enough to crack open my routine and give me the space to reflect on what is precious in life to me and to those I care for.
Each story affected me differently. The first left me feeling hopeful and glad for my dying patient’s choices and opportunity. The second left me full of despair and loss, not only for this patient, but for so many others.
As a family physician for more than thirty years, I know that it’s quite possible to go to work, to move from room to room, to greet, treat and repeat my well-practiced routine and, at day’s end, to leave feeling tired and numb, my sole thought being What’s for dinner? I could give you many reasons why this happens, but that’s not what this story is about. Or is it?
When a patient dies, we’re often left feeling empty, with no easy way to share our sense of loss. But when I’ve emotionally engaged with a patient and his or her family, I’m no longer grieving alone. And when I’ve helped my patients to get the care they want, and they can die on their terms and not feel violated, I feel that I’ve truly been a good physician and a caring friend.
I used to feel uncomfortable caring for dying patients. Like so many in my profession, I hid behind my stethoscope and my professional title. Now I enjoy this part of my practice. I have a lot to learn, and it’s not always comfortable, but it feels right and necessary. I now openly treat dying as a part of life. This isn’t a novel idea, but helping people to die well isn’t always valued in a profession that often views death as a sign of clinical failure.
With time and experience, I’ve learned that, for me, it’s these small human interactions, not the momentous medical interventions, that make the greatest impact on my patients’ lives and bring me the greatest joy in my practice.
A week later, Mrs. Stevens died at home, in the company of her grandson and daughter.
A month later, Mrs. Drake came to the office and told me about her new parakeet, Polly.
About the author:
Marc Tumerman has been a family physician practicing in Wisconsin for thirty-two years, the last eleven years with Mayo Clinic Health Systems, in leadership roles involving practice management and quality improvement. This is his second story for Pulse; he’s also had pieces published in Scope (Southern Illinois University School of Medicine Literary Journal), Wisconsin Medical Journal and elsewhere. “Like many, I’ve chosen to write about some of my more meaningful patient relationships because it’s these relationships that give meaning and fullness to my life. In addition, writing serves as a way to help me deal with some of the frustrations and limitations that life places on us at work and at home.”
14 thoughts on “At Day’s End”
Thank you for such a wonderful story. I have spent most of my career in hospice care and have learned so much from patients along the way. My state is specifically being targeted for Physician-Assisted Suicide legislation. Do you feel that doctors should be allowed to prescribe medication to end someone’s life, especially if they are terminally ill?
Dear Dr. Tumerman,
A beautiful story about three beautiful people: Mrs. Stevens, Mrs. Drake, and you. As Jack Kornfield has pointed out, empathy and attentive listening alone can leave us feeling emptied, as we feel others’ suffering, but adding compassion and how we can help (even if it is just our loving presence) fills all those involved.
Today I read two articles. The first was a summary of the medieval attitudes and prior actions of our president elect. This essay in The Pulse was the second. I feel more hopeful now being reminded that empathy is alive and well. Thank you.
thanks for the kind words. if I could accomplish that, even if only for a few hours, it was well worth it. marc
Thank you for writing and sharing this beautiful story of mutual healing.
What a gracious heart and mind you have.
I retired from my ( NP ) private practice ; these visits you describe were my lifeline. No pun intended. BTW, do you know my old 1st grade homey, Dr Pat Bryant, neuro in WI with Mayo? Oh well, we’re from Tucumcari ( NM ). We think everyone up there in WI should know everyone else! Bless you.
Jina, yes Pat is a partner of mine in Lacrosse area. His practice is in Lacrosse and am in a satellite primary care clinic about 20 miles away. But we serve on a committee together and I see him often! Small world. I will tell him hi from his 1st grade homey! marc
Thank you for sharing this story. It has made my day knowing that 2 lives were so specially impacted by a person who cared. Not many of us get that chance to have such an effect on another human being.
Thank you for sharing this meaningful story about how important the small human interactions are!
Thanks doctor for writing this wonderful story. I really liked the way the reflection led me along in a direction I felt like I wasn’t being rushed.
Thanks so much for this post. It has been a very hard 10 days but this essay reminds me there are other important issues to focus on.
Marc, beautiful. this is a wonderful (wonder-full) story, and it also embodies what narrative medicine is about. Listening to the STORIES that patients have to tell us of their illness, their suffering, their worries, their fears–their LIVES. After that for some, comes reflection, and expression of our (physicians’) own processing of the experience(s). And finally, some times, the sharing in story telling of those stories, and especially our experiencing of them. In this way we can share the REAL heritage of medicine, especially with younger colleagues who often have no one but us lone wolves’ voices in the dark wilderness to give them a sense of what is possible in medicine.
What a touching piece. Thank you.
Beautiful. Thank you for sharing this hopeful message with us.