Without Work

Frankie had worked as a barber in a small town for over 40 years.  It's important to note that in a small town the barber shop has its own sub culture. Men of all ages, from all walks of life and socioeconomic status, enter on equal footing.  The barber with blades in hand, is ruler of the roost siphoning in information from gossip, secrets, and confessions of clients. The power is all his, as the morsels he collects he can choose to hold tight to or to pass on to others.

For forty years the castle was his. Others clamored for his favor to win tidbits about others. He was respected. He was independent. His job was his life.

When they found a nodule in his lung he started chemotherapy in secret.  He had listened and passed on tales of countless other peoples cancer woes and didn't want the awe filled pity that accompanied the news.

He pushed through the fatigue and side effects, never missing an day at work.

The news came that the cancer was spreading rapidly, but he continued to ignore this reality. Finally one morning he didn't have the strength to make it to work.   With no work to go to, he called hospice.  Now he was ready to die.

I met Frankie the day he enrolled with hospice.  We talked about his life, his hopes, his disease.  I cautioned him that although his weakness and fatigue were preventing him from going to work it still appeared that he had several weeks left, if not a month or so before the end.

Word got out about Frankie's cancer, the very world of information exchange that he had controlled now passed around his own tale.

Without his job, Frankie floundered. He refused visitors, he lashed out at family. He climbed so inward into himself that he'd often ignore my visits. If anything was muttered, it would be about wanting to die.

It's as if, in Frankie's eyes, 100% of  his value was in being a barber and when that was taken away there was nothing left. No amount of medication, dignity therapy, or listening could fix the suffering from loss of identity.  It was agonizing. He laid in bed, rejecting the world for over a month before he died.

I've tried to funnel the heartbreak of not being able to help Frankie into a check up of my own self value. There's got to be balance of worth that comes from both external and internal things.

If only Frankie could have acknowledged that despite not being able to go to work, he was still a father, a grandfather, a friend, and still a barber with a lifetime of stories to be shared.

Pacemaker deactivation

When you least expect it, some moral dilemma may strike in the wards. I have been taking care of a young 46-year-old man. He, unfortunately, has a very bad heart.  It only pumps at about 20%. This bad pump function causes fluid to back up into his lungs and legs, making anything strenuous just impossible.  He even had a pacemaker and a “shocker” put into his heart. The pacer helps the heart pump and the defibrillator shocks his heart back into life if it stops- which it has done on occasion.  While in the hospital, we've been walking a fine line with him, of getting the extra backed up fluid off of him (we give him medicines to pee it off) while making sure his kidneys don’t stop working from the medicines we give.  There have been multiple specialists involved. He actually could have a better life- and longer life- if he took the initiative to loose about 50 lbs AND if he could tolerate some of the heart medicines.  Unfortunately, he feels that both of these options are impossible for him.  So we kind of limp on, with our meager medical tools- trying to keep him going. 

Yesterday he was to his baseline- his usual semi-short of breath, somewhat fluid overloaded state.  We had reached our medical end and were ready to send him home.  Things changed when he made an unseemly request.  “Doctor, Just turn it off”.  I stopped to clarify, “Mr. R, what are you asking?”  “Just turn the pacemaker off, I have thought about this for a long time. If there is nothing else medical to do, I just want the machine off and let me die” At first I thought he was just angry about being discharged from the hospital, trying to shock us into keeping him longer.  However as the day went on, and more and more doctors became involved it became clear- he was ready to die.

With the Shiavo case fresh in all of our minds, it’s interesting to revisit this area of medicine.  Very often we as doctors are confronted with prolonging and shortening life. It is not unusual for a family, gathered around an aged grandmother on a ventilator, after a stroke has left nothing but a shell, to request that the breathing machine be turned off.  Most of us wouldn’t hesitate to honor the family’s wishes, especially when convinced that the grandmother wished that they never wanted a machine to keep them alive. But when a living, talking, walking, laughing, man says he wants the device keeping him alive to be stopped- what then?  It’s the same scenario – a man-made machine is being withdrawn…without it in place Mr. R wouldn’t still be alive anyway.  So why does it feel so different than the old lady in the ICU?  The difference medically is non-existant, but perceptively the difference is drastic.  One situation feels generous and natural, the other feels like assisted suicide.

We stalled all day today trying to prepare ourselves as doctors, and as humans, to be okay with his request, as the patient was already okay with it.  We had psychologists, ethicists, cardiologists, and palliative care doctors (end of life docs) all come and comment on this unusual request.  All came to the same conclusion. It was okay- he was rational and competent enough to make this decision, and we, as physicians were required to follow through. 

So tomorrow morning, if things continue as planned, the nurse cardiologist in charge of these medical devices will come and turn this pacemaker/defibrillator off. His family will be there, all the doctors will be there, and we, with heavy hearts, will say goodbye.