Until Death Do Us Part

I removed Mr. D's bulky mask and breathing machine, revealing a bearded countenance with the pensiveness of Charles Darwin yet the jollity of Saint Nicholas. Given the freedom to take his own breaths, Mr. D appeared comfortable for the first time in weeks.

I reflected on the lessons I had learned while caring for Mr. D during an internal medicine subinternship rotation in my final year of medical school. By the time I met him, Mr. D's several month-long hospital course had taken a turn for the worse. With no spouse listed in his medical record, it was not clear to me whom to contact to discuss next steps. However, I learned from an observant night shift nurse that Mr. D had a faithful companion who had visited every evening without fail since he was first hospitalized months earlier.

One night while staying late in the hospital on-call, I met Mr. H. When I entered Mr. D's dimly lit room, Mr. H gently grasped Mr. D's hand, caressing the tortuous path of his wrinkled arm veins and humming melodies from Tchaikovsky symphonies. Mr. H explained that he and Mr. D had been partners for more than 30 years, but due to homophobia experienced in the military, he did not want to bring attention to their relationship in the VA hospital. I reassured Mr. H that they would not experience discrimination from any of the medical staff.

Later that week, I conducted my first family meeting where I summarized Mr. D's lengthy hospitalization, introduced Mr. H to the compassionate palliative care physician, and initiated a discussion regarding the prioritization of comfort. Because Mr. D lacked decision-making capacity due to his impaired mental status, we turned to Mr. H as a surrogate decision maker. Mr. H recognized that Mr. D had been suffering more and more over the previous weeks and wanted to focus on minimizing his discomfort while maximizing his quality of life.

After deciding to remove Mr. D's breathing machine, Mr. H ensured Mr. D's final hours would be filled with love. Family and close friends surrounded Mr. D's bed and recounted cherished memories of him, including his love for root beer floats and annual snorkeling adventures in search of the blue-lipped yellow-striped reef triggerfish in the Big Island of Hawaii. During my lunch break, I concocted a root beer and vanilla soft serve swirl for Mr. D using my meal ticket at the cafeteria.

A priest cloaked in black vestments from the cathedral arrived and administered last rites. Through the window behind Mr. D's bed, the Golden Gate Bridge stood like a silent sentry in the glistening San Francisco Bay. With Mr. H's permission, I participated in the ceremony and received communion along with Mr. D's other family members. Later in the afternoon, Mr. D took his last breath, his arthritic hand intertwined with Mr. H's.

As my first palliative care patient during medical school, Mr. D taught me immeasurably about the art of medicine. By caring for him, I led my first family meeting, worked with chaplains in the spiritual care department, learned to safely wean ventilator settings, and prescribed my first regimen of morphine for pain control. Mr. D was the first patient for whom I truly felt like doctor. Though I will remember Mr. D and Mr. H for their role in my medical education and for teaching me about palliative care, their greatest impact on my life was through their love. As a mixed race, Christian couple, they had supported one another in the face of enormous challenges and managed to create a loving modern family. Their steadfast love and affection through the decades, particularly during Mr. D's infirmity, inspired me: a few weeks later over Thanksgiving dinner I finally came out to my family. At Christmas I introduced them to my partner, Ryan.

Despite our initial fears, Ryan and I received unfaltering support from our families, particularly from my parents, both ordained pastors in Asian ministries. Perhaps because of the stress of coming out coupled with the grueling demands of clinical training and the competitive residency application process, I developed a massive ulcer leading to a gastrointestinal bleed after Christmas. ¹ Ryan and my parents took shifts at my bedside day and night for my entire month-long hospitalization. We all grew closer in the cramped ICU room, recounting family holiday memories, watching movie marathons including the entire Harry Potter saga, and counting down the seconds to the New Year, celebrated with flimsy apple juice cups from the hospital cafeteria. Ryan supported me through every step of my recovery, bathed my skeletal frame after weeks of not eating by mouth, lugged my pole of IV fluids and medications as I sauntered around the hospital unit, and endured through countless meals of bland porridge with pureed chicken after I was discharged from the hospital.

Same-sex marriage became legal in California later that year. Against the backdrop of the Golden Gate Bridge and azure light shimmering on the San Francisco Bay, I proposed, and he said yes. My Chinese Tiger Mother, ² who has always advocated on my behalf since childhood, steered heated discussions for several months at her conservative church until the congregation elected to support same-sex marriage. The Diocesan Bishop, towering over the altar like an Italian don and clad with ornate ivory chasuble and miter, officiated over our wedding, his first legal same-sex marriage. After walking down the aisle hand in hand, I gazed into Ryan's hazel eyes and recited the vows we had practiced every night for the prior six months: “… in sickness and in health, to love and to cherish, until death do us part.”

Same-sex marriage has many health benefits, particularly since lesbian, gay, bisexual, and transgender (LGBT) individuals often face challenges and barriers to accessing health services and as a result can experience worse physical and mental health outcomes, particularly in older populations. ³ Same-sex marriage facilitates the medical decision making of couples who might not otherwise be legally recognized to make medical decisions at the end of life. In addition, same-sex marriage improves access to healthcare insurance for LGBT persons and may provide spousal, survival, or death benefits through social security. Older LGBT populations grew up in periods of less social acceptance for LGBT lifestyles and, therefore, may have greater fears of social stigma and discrimination than their younger counterparts, which may prompt them to conceal their sexual orientation when seeking healthcare and entering senior housing facilities. ⁴

I feel incredibly fortunate to have experienced love and marriage after marriage equality was realized in California, an opportunity that unfortunately eluded Mr. D and Mr. H. Ryan accompanies me to all of my follow-up endoscopies and is listed on my medical record as my husband, thanks to an eager third-year medical student's detailed social history. We have never faced any discrimination in terms of medical care or decision making as husbands.

When Ryan and I attended the Easter vigil service in San Francisco last spring, I spotted Mr. H as the sun's auburn glow began to illuminate faces of worshipers in the cathedral's nave. We greeted one another with a hug. I finally revealed to Mr. H what an inspiration his relationship with Mr. D had been to me at a critical time in my personal life. I introduced him to Ryan. Mr. H smiled and pointed toward the Gothic bell tower of the cathedral, which housed the columbarium containing Mr. D's ashes, and said, “I know he is smiling over both of you. He always believed in the power of love.”