Abstract
At first glance, he looked just like any other patient waiting to be seen. However, upon closer scrutiny, I noticed that he held his sling bag close to him as he sat in the chair, with quick darting glances around and had his cap pulled low like he was hiding something or from someone.
“Hi, Mr. Meyer,* I'm Dr. Khoo, and I'm taking over from Dr. Smith.* How are you today?” I asked. My attending physician had warned me that Mr. Meyer takes a while to warm up to new people, and was quite attached to the previous palliative care fellow.
“Good,” was all I heard, with a quick nod of his head. His eyes continued to dart left and right, never quite making eye contact with me.
“Have you had any pain?” I asked. I got a shake of his head.
“Any shortness of breath?” Another head shake.
“How are your bowels?” I asked again.
“OK,” he whispered.
“Are you having a bowel movement daily?” A quick nod of his head.
“How are you doing at home?” I continued.
I knew he lived alone, and had declined any home health or hospice services. He had been fiercely protective of his independence and privacy, refusing to allow anyone into his home except Kate,* his community social worker whom he had known for many years. As I glanced at his documented weight today, I knew that he had lost another 10 pounds since he was seen four weeks prior. This ongoing weight loss remained a problem despite the nutritional supplements he had been taking, and this worried me.
“Good,” he responded, almost like a broken record.
“How's your cat?” I asked, trying another strategy. I had read from previous clinic notes that he had a cat he really loved. This made him look up, in surprise. For the first time, his eyes looked right into mine and I noticed that they were hazel-colored.
“Good.” He said. He looked down again. But this time, he perceptibly relaxed.
I knew this strategy was working, so I pressed on.
“Do you have photos of your cat? What's its name?” I asked.
“Mia,*” he said, as he reached into his bag and brought out an iPad. After several quick and deliberate movements of his index finger, a slideshow appeared. The next 15 minutes were spent looking at his collection of photos. I couldn't help but notice how impressively tidy and clean his apartment was, despite his failing health. I learned that he recently got a red convertible, and as I expressed my surprise and admiration of the car, I could see him beaming with pride out of the corner of my eye. I could tell that investing in those 15 minutes was the best thing I could have done for both of us that clinic visit.
The rest of the visit was relatively uneventful and only substantiated what I had suspected, that Mr. Meyer was on an ongoing downward spiral of debility from the underlying malignancy. The fatigue was getting worse, and he was unable to cook anymore, relying instead on sandwiches and nutritional supplements. I gently offered to arrange for supportive services for him at home. As soon as the words came out of my mouth, he visibly stiffened and shook his head. As such, I merely refilled his pain medications and requested to see him back in two weeks.
The next time I saw him in clinic he was able to maintain a little more eye contact with me, though never for more than a few seconds at a time. Like before, he didn't offer much of a verbal response to any of my questions, but with some targeted questioning, I was assured that his symptoms were under control with the medications. He again declined any assistance at home. Once more, he would brighten up whenever I asked about Mia. This time, though, he gave me a smile before he left the clinic. That little facial gesture felt like a precious gift coming from him. He was scheduled to return to clinic two weeks later.
However, he never made it to clinic. A week later I was paged by the on-call medicine resident. Mr. Meyer had been admitted to the hospital overnight, after he was found to have been falling down at home. Kate found him unkempt and disheveled, and brought him to the ER. Sadness overcame me as I listened to the resident's narration of what had happened.
I made my way to Mr. Meyer's room knowing that the conversation we were about to have was going to be difficult. I knocked on his partly opened door, and he nodded for me to enter.
“Hi Mr. Meyer, it's Dr. Khoo. I'm sorry to see you here. Sounds like you've been having a rough time at home.”
He nodded. For the first time since I met him, he appeared defeated. We talked about how he was doing (I did most of the talking), and he admitted that things had worsened over the past week.
“Perhaps you could come up to our inpatient hospice unit, so we can help take care of you,” I offered.
He looked out the window and mumbled something.
“I'm sorry, I didn't hear what you said,” I responded.
“The death row, that's where you go to die,” he asserted quietly.
His comment caught me by surprise. Not just because of the high content of that simple statement, but also because that was the longest sentence I had ever heard him utter.
I pondered what he'd said. There was no denying the truth in his statement. I knew it, and he knew it.
“The cancer has made you a lot weaker. You've been doing so well at home, but now I think it's time that you allow us to take care of you. We'll make sure that you're comfortable and that your symptoms are under control. We'll be there with you throughout,” I said softly. He thought about it for a minute and then finally nodded.
We made arrangements to have him admitted to the inpatient hospice unit. Over the next week we made sure that his pain was adequately controlled, that he could have all the ice cream he wanted (chocolate was his favorite), and that Kate could bring Mia in for visits. On the days that he saw Mia, Mr. Meyer was noticeably happier. He did not have many friends, and the only visitors he had were Mia and Kate.
The hospice interdisciplinary team extended their support to him as he spent his time on the hospice unit. However, for the most part, he declined their visits, preferring instead to sit by himself in his room. I caught him staring out the window often, and wondered what he was thinking about. At times I would stop by and just sit with him, but I was never quite sure if my presence was what he wanted. How does one help a person who has been socially withdrawn all his life go through the dying process?
The only concern Mr. Meyer raised during his time on the hospice unit was about Mia. He wanted to know what would happen to her once he was gone. Kate told him she would take care of Mia, and he nodded. I noticed that his eyes were suspiciously wet.
I guess it is true what they say, ‘We die how we lived,’ but how do people like Mr. Meyer who have lived most of their lives in solitude experience the dying process? Would they appreciate company, or would they much rather be left alone? Is their experience of anticipatory grief that much more intense because they are unable to share it with others, or is it less because they have fewer emotional attachments? I wish I knew. Regardless, one thing I did know was that as clinicians, we need to meet the needs of our patients on their terms, not ours.
* Names changed to protect privacy.