The last reprogramming

By Westby G. Fisher, MD, FACC

He had called the other day to update me up on his condition. He did not sound upset, but resolute. “They offered me peritoneal dialysis,” he said, “but I decided against it and figured I’d just let nature take its course. The hospice people are so wonderful – I’ve got things all set here at home, but I have two questions. What should I do about my warfarin? You know, I just don’t want to have a stroke. And what I do about my defibrillator?”

We were colleagues once and grew to be friends later when life’s circumstances brought us together. He, a revered senior neurologist and me, a relatively new doctor in town. I could remember overhearing his heated discussions about administrative snafus with colleagues in the hall, or watching a horde of residents and medical students following him into a patient’s room to teach at the bedside.

“Of course he didn’t want a stroke,” I thought.

So we decided to keep the coumadin and let him continue his daily INR checks at home and to turn off just the tachyarrhythmia detections on his biventricular defibrillator.

“I’ll come over tomorrow and we’ll turn it off,” I said.

There was a brief silence, perhaps because of momentary disbelief that I’d do such a thing. Then he proceeded to give me detailed directions and landmarks to watch for on my way over. “I’m sure I can find it,” I said thanking him.

So the next afternoon after most of the day’s events had finished, I grabbed the programmer and drove to his home. It was an unusually beautiful day – mid 70’s, sunny – as if Someone had wanted it that way. There in the yard, was his wife, wearing a large-brimmed hat and holding a hose while pretending to water the shrubs. She came over to greet me: “Thanks so much for coming over,” she said, “I know this means so much to him.” Then she realized she was still holding the hose. “Oh, I’m so sorry, it’s just that someone has to try to keep the place up,” she said, voice cracking.

The “place,” of course, was beautiful. A majestic grande dame of a house – one I would later learn they had occupied for the past 44 years and bought when they were “just kids on the block.” It was meticulousy kept, stately. I entered with his wife and noticed a shadowy figure two rooms away sitting at the edge of a mechanized hospital bed. The bed was placed in what must have been his study with a large bay window with a couch next to it. A reading lamp was over the head of the bed and the walls held books from the floor to ceiling with icons and statues, likely from other, more active time.

“Thanks for coming, Wes,” he said, looking up.

“How are you feeling?” I asked, somewhat stupidly.

“Pretty good, considering everything. See? My legs aren’t quite so swollen and my abrasions all have eschars on them,” he noted as only a doctor could.

“Is there a plug nearby?” and he proceeded to point me the way so I could plug in the programmer to do my job while he explained the device to his wife. The process was quick and I interrogated his defibrillator, then turned off the tachyarrhythmia detections, therapies and now needless alarms. “There, that didn’t take long. All done,” I said.

There was a moment of silence as I sat with this man whom I known for so long. Like a wise sage and hospitable host, it was clear he wanted to talk for a bit, so I slowed my exit.

“You know, I’ve always appreciated your frankness about my condition,” he said. “You’re a lot like me in many ways, I think.  You never overstepped, let me have control, to manage things like I wanted to, and I’ve always appreciated that,” he said.

Embarassed by his frankness, I wondered what to say. At a loss for words, I told him how much I enjoyed meeting his family, wife, daughters, and grand-daughters recently in the hospital. He looked puzzled, forgetting. “You know, that day I brought my daughter in your room with them?” His eyes brightened and his smile widened as he remembered.  

“Oh, yes! That was wonderful!  How fast times flies, doesn’t it?” he said.

“You know, I wrote about that day in my blog,” I mentioned, “.. and included some pictures of my daughter from 10 years ago – about what she thought about medicine – can I show you?”

“Of course!”

So I showed him the picture and we shared our thoughts about family. Then, to make reading from my iPhone easier, I read him the post I’d written about that day. We talked about family and what they meant to each of us. And then he shared with me another nugget, that he grew to become a writer, too.

“You know, I spent some time and wrote an autobiography for my kids not too long ago – over a hundred pages – about everything I could remember – from my earliest years as a child, about my immigrant father and American mother. My father made it as a successful lawyer – came over from eastern Europe – I even know the ship – I remember the picture of him standing there with his hat…, and I wrote about my family, influential teachers in grade school, fellow professors, and people that I knew throughout the years – everything. You should do that, too, you know. I’m so glad I did. I gave them to my kids and even made some some extra copies – maybe for the grandkids, in case they want it someday…”  He looked away to see his wife leave the room, trying not to be noticed as tears filled her eyes once more.  She didn’t want to him to see her this way.

He stared down at the floor beneath his swollen feet, then continued.

“You know, it was therapeutic for me to write that autobiography. After all, what we do is terribly isolating for the most part. No one understands that. Like you do your procedural stuff and I do my diagnosing. We do most of it all alone, with no one else there. Just the patient and the doctor.  Wonderful, to be sure, but isolating. So many memories. I guess it helped me to put some of those feelings and the thoughts I had about those I loved into words. It’s hard to capture it all…”

He looked up from the floor and stared in my eyes. “Thank you,” he said extending his hand.

I sat motionless for a bit digesting the gravity of his words, lost in them before I saw his hand. Once I noticed, I lept up to shake it and gave him a long hug to his increasingly skeletal frame. It was a brief moment to share together once more and one I now realized I had done too infrequently with other patients in a similar circumstance. Here he was, an incredible man who’d given so much to his family, fellow colleagues and patients, now teaching me once more so much about life as a doctor, about grace, and about real love. Just the two of us, isolated again, but as friends.

With great reluctance I packed things up and found his wife on my way out. “Thank you,” she whispered with swollen eyes, “I just don’t want him to be in pain.”  

“He’s going to be fine,” I told her, “… perfectly fine, especially now. He’s such a wonderful guy.” She smiled and opened the door.

As I drove away I realized we probably won’t see each other again – his remaining time here will be saved for others now. There were so many thoughts, so much to remember, so much still to learn. Perhaps because I’d been through something like this before I was more prepared – it’s never easy – but I still felt okay about it all – not sad – confident that we did the right thing…

… together.

-Wes