On Wednesdays, one of the residents in my clinic precepting group usually presents a didactic. However, last Wednesday, the junior resident was absent, and I decided to present a case of a “challenging patient” instead. The patient himself wasn’t really challenging, I explained to the residents, but he was in a challenging situation. I had a 20-minute telemedicine session the following day, and I wanted the residents’ advice on how I should best spend my time with the patient.
Mr. A. was a ninety-something year old man whom I first met during the COVID pandemic. His posture was stooped, his face unshaven, his blue eyes bright. He had attended a university in Boston, was a Korean War veteran, and had restored paintings at the Smithsonian. Estranged from his family, he lived alone in a community outside Boston, was still driving, and had hot meals delivered twice a day. I would see him about once a year.
About six weeks ago, he presented for a routine primary care visit with me. A week prior to his visit, he had fallen, and he reported that his energy level had been low for the past month, he became out of breath doing simple tasks, and his heart was beating faster. On top of that, he was upset about a dispute with his neighbor over some trees on the property line, and had to go to court. The combination of his irregular heart rate, scaphoid abdomen, swollen calf and a near-fall in the exam room prompted me to send him to the emergency department, via ambulance, to rule out a pulmonary embolus.
A ten-day hospitalization led to a new diagnosis of metastatic lung cancer. He saw the oncologist only once, where he expressed concern about the potential effects of treatment on his quality of life. He conveyed to the oncology team that he is currently managing to take care of himself; he is able to enjoy classical music, he likes listening to J.S. Bach and “going about his day.” He stated that any type of interruption in his routine did not fit into his goals of care.
I presented Mr. A’s case to the residents. I had called him after his discharge, and he had seemed very depressed. Should I do a PHQ 9 screen for depression during the visit? Did he need to see the palliative care team? My senior resident, wise beyond her years, expressed empathy, and stated the obvious: the patient is dying, and he wants to preserve his independence.
The time for his telemedicine visit arrived on Thursday morning. It looked like he had cancelled the visit, but he was still in my schedule. I called twice, and the phone rang and rang. I wondered if he had died, alone, in his house. The next day, I received a text asking me to sign his death certificate. I texted my residents and let them know the patient had died.
Saturday morning, I was playing the cello, rehearsing Beethoven’s “Ghost” trio. As I played through one ethereal passage, I imagined Mr. A, listening above us.
Karen E. Lasser
Chestnut Hill, Massachusetts
4 thoughts on “Quasi Niente”
I understand your patient. My husband refused chemo and lived out his life on his own terms. As such, instead of dying in a few weeks as he was warned, he lived six months, five of which were healthy and good. His decision was unusual to his friends, and he made me promise to write a book that might help others. So I did. Mr. A was a wise man!
I can’t adequately convey how much I like and admire “any interruption in his routine did not fit his goals of care.” I have cancer. I have four appointments next week with three different doctors and one MRI facility. I have three surgical wounds healing as I write this. All of this interrupts what I would like to have for a life. Maybe part of the art of life is knowing when to say “It’s enough; I don’t want to interrupt my routine any more.” All this to say that I don’t know when I am going to use your patient’s line, but I’m stealing it. And I know it will feel great to say it.
Lovely piece. I think I would have liked your patient Mr. A. Thank you for sharing him with us.
Thanks so much, he was a lovely man.