Abstract
He never takes his blood pressure pills. He says he feels fine without them. Over the years, he has refused preventive care: “Don't get near my prostate. If it's not broken, I don't want you messin’ with it.”
I watch him walk down the hallway, reaching for the wall with his left hand. He's wearing a khaki overcoat that swamps his shoulders. My nurse leads him into the examination room where I greet him.
“John. So good to see you. What brings you in today?”
He's been coughing since I entered the room.
“This cough, doc. I know I need an antibiotic.”
“This cough” is a bloody cough in a 74-year-old man who smokes a pack of cigarettes a day. I watch him pull a tissue out of his pocket and spit blood. I note the dark rings under his eyes, and his shaggy, white hair that's thin on top. His skin is tan and wrinkly from years of work in the tobacco fields of Virginia. As far as I know, he never married. He has no living relatives. He lives alone on a small farm not far from town. He still mows the fields himself.
I ask him a few more questions, and then listen to his lungs. There are crackles at the right base.
“John, I'd like to do a chest x-ray. You may have pneumonia. However, as we've talked about before, you're also at risk for lung cancer. I'm not saying that's what it is, John, but we need to see what's going on.”
“Don't bother with it, doc. I'll be fine. Just give me an antibiotic.”
I do what I can to persuade him, but he will not budge. I prescribe an antibiotic, and he agrees to follow up in several weeks.
When he doesn't show up for his appointment, I call him. I call him again. I call two more times later in the week. Finally, he answers.
“Yes, I'm better,” he says.
“Are you coughing up blood?”
“Not much.”
Not much? Three weeks later, I see his name on my schedule.
“More blood,” he says. “I don't feel so good.”
He doesn't look so good. His skin is gray and pale. He's lost eight pounds. His overcoat looks even bigger than last visit.
Then, after years of saying no, John says yes.
He says yes to the chest x-ray. He says yes to the CT scan. Yes to the subsequent bronchoscopy, chemotherapy, radiation treatments, tertiary care referral, and hospitalizations. Yes to the questions about code status.
Nine months pass. I visit John in the hospital. In the parking lot, his oncologist tells me John's cancer is everywhere—the treatments are obviously not working. Worse, they are making him sick. When I get to his room, the lights are off and the shades closed. I quietly move to the side of his bed and watch him sleep. He has long tubes in his arms, nose, and penis. When I rub his shoulder, he opens his eyes and tells me the feeding tube hurts like hell.
“I can't breathe either,” he says.
I gently tell him what the oncologist told me. I tell him it's time to say no to doctors, chemotherapy, intravenous lines, feeding tubes, and machines.
“I can do that, doc. You know that better than anybody.”