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Sometimes I provide
medical coverage to our local hospice. On a recent trip to the
ward where people come to die, I visited an elderly man who had
just been admitted with a case of pneumonia that he’d chosen
not to treat any further. He saw this infection as the final act
of a several-year-long drama, during the course of which he’d
lost his vigor and his independence. He’d outlived his spouse
and all his friends.
My patient was ready to die. Which does not mean he’d lost
his sense of humor. After obtaining the usual initial medical
history I asked this man if there was anything he needed –
thinking, of course, about pain medicine or a sleeping pill or
something for his bowels. He responded, “A couple of cute
nurses and a beer.”
This octogenarian was oriented to times when nurses were women,
when it was assumed that everybody was heterosexual, and when
speech wasn’t so constrained by political correctness. I
laughed when he admitted he’d already had his first wish
fulfilled by the two cuties who had gotten him settled into the
last room he might ever see in his life. And I was more than happy
to write an order for “Beer PRN.” (“PRN,”
a common medical abbreviation, comes from the Latin “pro
re nata,” meaning “as needed.”)
When the nurse who took the order--I believe she was one of the
“cuties” my patient had referred to – asked
me “How much beer?” I said, “As much as he wants.”
I cannot imagine any other beer order for someone at this man’s
stage of life. Which is one of the things I love about working
with hospice patients. Comfort is the paramount goal. I don’t
have to take into consideration dosages, side effects, or drug
interactions, except to the extent that they might interfere with
my patient’s comfort.
Occasionally other goals, such as lucidity or surviving until
a loved one arrives, do need to be taken into account when ministering
to the dying. But that wasn’t the case for this man. (Notice
I didn’t say, “For this unfortunate man;” he
was peaceful, ready to die, comfortable, and attended to by loving
family.) I wasn’t around for the end, but I’d bet
it was a good final scene to the tragic last act of his life’s
drama, leavened as it was by his attitude of cheerful resignation.
My patient’s wit and lack of political correctness speak
to another of the reasons I like working with the dying. It’s
a time when there’s little reason to say anything but exactly
what you mean to say. At the end of their days, people tend to
be blunt and sometimes funny. And they appreciate those traits
in others. It’s a refreshing way to relate – there’s
just no room for bullshit.
As a typical doctor who has been trained to take myself and the
demands of my profession very, very seriously, imagine what a
pleasure it is to find a group of patients for whom I don’t
have to worry about much more than keeping them comfortable and
talking to them straight. In many ways, the stakes are lower with
hospice patients than with those whose life I am working to preserve.
If I order too small a dose of a narcotic to control the pain
of a dying patient, a nurse calls me and I increase the dose.
If the dose is too big, the patient will be comfortably over-sedated
for a while. Life and death do not hang in the balance.
Why, then, haven’t I chosen a fulltime career in hospice,
where the emotional payback to overseeing “good deaths”
is so huge and the consequences of making a bad decision so small?
Because it wears on me. No matter how comfortable I get with dying
as a regular part of living, I eventually get worn out by all
the straight talk and open emotion. Though I don’t ever
don a white coat nor often refer to myself as “Dr. Ringel,”
I need the option of retreating to a respectable professional
distance at least some of the time in order to keep from depleting
my emotional batteries.
I’ve decided to share here some of my intimate feelings
about what it’s like to doctor the dying because, when it’s
time for you or a loved one to face death, you are liable to get
more of what you really need from your physician if you know something
about what makes him tick. And I tick like a pretty average physician.
Almost any time you’re telling your story to a doctor, the
back of his or her mind is probably filled with lists of possible
diagnoses and how to rule them in or out. As the doc writes each
prescription there’s a monologue going on in his head about
how that drug will affect all of your conditions and interact
with all your other medications. Like it or not, only sometimes
does a physician feel like he has the luxury to just plain listen
and decide what will make you feel best in the short term. The
end of life is one of those times.
If you can muster it, show some patience and compassion in relating
to your doctor. When necessary, repeat what you know he really
needs to hear. If he seems incapable of ever really hearing you,
get another doctor.
People such as that dying man teach us that humor always helps.
Even if you’re not old or sick enough to get away with being
politically incorrect, you can still see to it that everybody
feels at least a little better by keeping an eye on the funny
side of things.
And remember: no bullshit. Your doctor will find it refreshing.
No matter what the time of your life, you’ll make the physician’s
job easier if you can let her know exactly how you feel.
If you really want to give your doctor a thrill, reward her with
the opportunity to write an order for “Beer PRN.”
You’ll be on your own, though, when it comes to asking for
cute nurses.
Marc Ringel has spent the majority of his career
as a family doctor working in rural communities, including the
last 12 years in Brush, Colorado. He has written extensively,
for lay and professional audiences, about rural health, medical
informatics and healing.
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