Abstract
Instincts are fascinating. Fear, anger, affection, sympathy, and love are examples of human instincts and nesting is an example of a powerful instinctive behavior. Nesting is observed in several species, and among humans it precedes a baby's birth or a child's adoption, compelling the expectant parents to organize their life and their surroundings. The nesting instinct may include tasks such as finding a stroller, washing clothes and putting them in the dresser, cleaning toys, and making up the bed with sheets and a blanket. All this occurs to prepare for the new arrival. If birth or adoption is the catalyst for nesting, are there other significant times in one's life for the nesting instinct to re-emerge? For instance, what about a rapidly approaching death? Death is such an overwhelming experience that nesting behavior might surface and provide a focus and help organize necessary tasks while one is preparing for death. Nesting at the end of life might include cooking and storing food, gifting clothes and pictures or other personal objects, ensuring all the numbers and passcodes for important items are written down and locatable, and saying goodbye to the people you love. Does nesting behavior occur before the end of life?
A new patient was waiting for me in the examination room. He was a big man with a large fleshy nose, prominent ruddy cheeks, and a full head of salt and pepper hair. Even when he was sitting on the examination table, his frame filled the room. Despite his size, he exuded a vulnerability and softness. He smiled freely and he had perfect teeth. I closed the door and introduced myself to him and shook his hand. He looked over my shoulder and I followed his gaze to a small woman in the corner of the room sitting next to the door and against the wall. I had completely missed seeing his wife! She was small and fragile looking, and I quickly extended my hand to greet her. She did not look well. And although she was small, her hair was huge, golden-brown, and styled in a loosely curled bouffant circa 1960s. Her eyes were dark and piercing and they made her look determined but not menacing. I had the sense that she was giving me the “once over” and she was going to test me. “Bring it on,” I thought.
My patient was 85 years old and recently hospitalized for uncontrolled epistaxis leading to anemia and syncope. The clinic visit went smoothly. Since his discharge, he had two subsequent and easily controlled nosebleeds. He had a few other chronic problems that we discussed and established a plan for each one. His wife was watchful and asked pointed questions regarding the next steps for her husband. I asked them to visit the laboratory and obtained some routine blood studies to check his anemia. The hemoglobin had increased and that evening I called them to tell them that his anemia improved and he did not require a transfusion. They were happy to receive this information and even more pleased that I phoned them. I did not think this was so special but they did. Yes, I did care about this patient and I would follow-up.
Three weeks later he returned to see me, again accompanied by his wife, and his major complaint was a “lack of energy.” He was sleeping all the time. His wife said that he did not want to shop, an activity they had enjoyed together for more than 60 years. He did not have any more episodes of epistaxis. After asking a few more questions and examining him, I noticed that he seemed forlorn and sad. I asked him whether there was anything going on in his life that was upsetting him. He looked at his wife and she stared at him. “Go on tell him” she commanded. He looked at me and this large man with a gentle manner just shook his head and said “no.” “Oh, for Christ's sake” she snapped. “I have inoperable lung cancer.” She must have carried this diagnosis before I first met her, when she was initially sizing me up. I looked at her husband and his chin nearly touched his chest and his tears traveled down his red checks. I walked over to her and asked her how she was feeling. She replied by saying that she was fine. Their children lived nearby, and a cousin was constantly bringing them food. I asked him whether this was why he seemed sad and why he lacked energy, and he nodded yes. We talked more, and, in the end, I suggested that he begin an antidepressant. He agreed and as they left the examination room I wished her well.
Two months passed and he returned with his wife. He felt better, and his wife confirmed that his mood had improved. He was more attentive while she underwent investigational chemotherapy. His medical issues were stable, and he was more engaged during this visit. He was still sad but seemed less helpless, and during the visit she appeared relieved and more relaxed. He was out of the “danger zone” while she was entering it.
He returned to see me four months later. His wife did not accompany him. He looked despondent and the first thing he told me was that his wife was dying at home in hospice. He was not sleeping well and asked for a medication to help him sleep. We talked for a bit about how the family was coping with this new reality. I told him I was planning to write a story about them. The story focused on my impressions of her and how important it was to her that he was in good health and recovered from his illness. He asked me to “hurry up and write it; it would mean the world to her to know that my doctor thought of us and wrote about us.”
His urgency touched me, and I realized how important it was to ease her worries and help her prepare for her death. She probably had tests, small challenges, for others to pass before her death. My test was to ensure that her husband's medical and mental health care met her standards and that I truly cared about him. Her nesting behavior at the end of her life provided her with a focus and motivation to ensure that her husband achieved appropriate and attentive health care. I have learned that before her death, and from her hospice bed in their home, she organized their finances, and set up chores for her friends and family to accomplish when she died. I thought about her nesting instinct and the urge to organize and prepare for her death and I hope she was comforted that I would be available to her husband and help him receive the best care possible. I hope I passed her test. She died several months after reading this essay and she was happy I wrote it and shared it with her.