The Dying Man

Every physician has found himself in the borderlands accompanying a patient travelling from this world to the next.

I’m certain every physician wonders, at least once, with at least one patient, where the proper limits of his role are in this strange terrain?

When is alleviation of suffering more important than extension of life? And when does alleviation of suffering cross into euthanasia? If a patient asks for surcease, what is our duty?

I have no answers, but I do have a story, told to me by a fellow physician in a dive bar in Durham. After 40 years, he still grapples with the aftermath of such an encounter.

Names, places, and various elements of this tale have been altered to maintain confidentiality.

The Dying Man

Can my words conjure for you an apt portrait of the Dying Man? With trepidation I bare to you the mark his death has blazed upon my life.

Cadaverous and yellow, he gazed at me with eyes devoid of expectation, dulled with pain. His mouth was overdue for care, and flecks of dried spittle festooned his lips. He looked too moribund to speak, and yet he addressed me politely:

“Good day, Doctor, how are you?”

“Fine, but how are you?”

He laughed, low and hoarse.

“I’m dying fairly well today, but for the fact that I could really use a Scotch.”

His brand was Pinch, and he’d been a functional alcoholic, a  doctor of Philosophy, a PhD. highly esteemed at the local University, for as long as any of the medical students, residents, or young attendings could remember.

Functional, that is, until bouts of recurrent pancreatitis without evidence of gallstones began to raise eyebrows among the medical staff. But this was years ago, when despite a tell-tale pattern of abnormal liver blood tests and numerous psycho-social clues, no one dared (or cared) to address the silent sin of his drinking. Too bad, and so no one intervened as his pancreas slowly turned to soap (saponification). Now that a few renegade cells from that abused organ had turned as ugly and malignant as they could be and had obstructed the drainage of his liver, none could save him.

So, given his exalted academic status, and the distaste of his young wife (his third) for his stink and his skeletal frame, he was living out the last of his days in a private room at Everyone’s Hospital, where I was a scared, stubble-faced, loan-poor resident.

Although I was overworked and afraid of the terminally ill, I found it somehow restful to round on the Dying Man. He was urbane, witty and cynical—He was the first of the dying that I could see as a person. He made me look beyond his cancer at him, a man. He was dignified, even regal, which made his shocking jaundice and cachexia, and the raw appearance of his pressure sores look less awful to me with each passing visit. I saved my time with him for last in the day.

He seemed truly interested in me, as a young doctor, and as a person as well—I found myself (internalizing my guilt, as it wasn’t considered professional behavior) showing him a picture of my fiancée, who I now barely saw, courtesy of my 80+ hour work week at the hospital, and talking with him less as a patient; more as a friend. Passing by his room in the wee hours while on call, I would peer in at him, and listen in the dark for a few seconds to his ragged breathing. Then I’d feel drawn to the well-lit nurse’s station, where I’d review his chart, try to think of some improvement in his care, some way to make him more comfortable. I made sure no one checked his vitals in the night, to avoid disturbing his restless sleep.

The Dying Man was a fixture on the Oncology ward. In the mornings, during formal rounds, he would try to provoke me into inappropriate laughter. He would look at me and roll his eyes behind the back of his dapper oncologist, the renowned Dr. Eldridge Neebles, whose crisp morning monologues, aimed at residents and patients alike, were delivered at the bedside. As the oncologist’s clipped tones evoked research protocols and sophisticated poisons, I could barely restrain my fatigued body from sputtering out a few snickering snorts. On one occasion, I had to excuse myself, feigning a coughing attack. The Dying Man said I needed to get into trouble more and would be a better doctor for it. I listened, half-aware that he might be right.

Then, disaster struck—bowel obstruction. Its pain, vomiting, and distension make for an indecent and undignified illness. During the second night of this new ordeal, he cried when the nasogastric tube became dislodged, and I had to replace it. His nose bled, I felt awful, and for just a moment, the erudite professor became a child. There was a new distance between us after that night. He clearly resented that I’d witnessed this fall from his carefully-maintained pose of “The Gentleman Fades Gracefully”. I had hurt him. My times with the Dying Man now contained a bit more pain and awkwardness.

It was a relief to rotate off the Oncology service, and I evinced little curiosity when I heard that despite the Dying Man’s poor condition, the surgeons had taken him to the O.R. to try and fix the obstruction. My head and hands were now fully engaged in the busy Trauma service, and I let the Dying Man on the fourth floor slip from my mind.

I was in the ER, writing a prescription of ibuprofen to give to the victim of a minor automobile accident, when the page came from the fourth floor cancer ward. Annoyed, I snapped at the nurse on the phone.

“Jefferson’s on call for Oncology, why are you paging me?”

“Dr. Jack wants you.”

My heart contracted, and I bolted the stairs two at a time to the Dying Man’s bedside. He looked horrible. His awful protoplasm had failed him once again. In the past day or so, the wound from the recent abdominal surgery had dehisced (come apart), and now his swollen belly was held together with newly-placed, thick, black, retention sutures. He was groaning, half-awake, and at first appeared not to recognize me. Then a faint ghost of his cynical smile materialized.

“Ah, Doctor, thank you so much for coming by. It appears that once more I require your assistance.”

Oh, God, what did this man want from me? My voice cracked in reply—an apprehensive croak:

“What…what do you want?”

He looked at me with intensity. Suddenly, any trace of a genteel façade vanished. The Dying Man spoke bleakly.

“Help me. Neebles won’t.”

“Help you? How?”

“I want some Pinch, and I want to die.”

Feeling suddenly swollen with dread, I backed out the door. Nearly dumb with dismay, half-mumbling platitudes through numb lips, I fled.

Damn him, he didn’t die. He was still alive the next night, and the next. Six endless days passed, he still breathed, moaned, as I passed his door in the night, and my stomach was a hard, sour knot. On the seventh, I reflected, cried, decided.

On the eighth day, praying for sepsis, fire, atomic war, anything to make action on my part unnecessary, I made an excuse to leave the hospital. I spent fifty bucks I couldn’t afford, and in a surreal, unbelieving haze, bought the Pinch. I put it in my locker, where I stared at it in consternation as I prepared for my long night on call. I waited, impatient and anxious, until 3 am of my shift, when the plethoric night nurse routinely dozed at her station.

Even in those days, it was hard to steal morphine. Trading upon my sterling reputation, empowered by my vicarious anguish and the thought of the Professor’s impotent desperation, I scraped together about 90 mg. I hoped it would be enough.

As I entered his room, he opened his icteric eyes. He eyed the tools I laid upon his bed and lanced me with his sardonic gaze.

“Tsk, tsk, Doctor, now you will be in trouble if you are caught.”

He reached for and grabbed my hand with his wasted one.

Looking at his brave, dissipated face, I felt a moment of clear conviction, for the first time in what seemed like forever. The frenetic fog in which I routinely existed while toiling in the chaotic atmosphere of this intercity hospital briefly cleared. We looked at each other, two finite souls, pretense suddenly stripped away.

I gave his hand a quick squeeze in return and we smiled wryly at each other. We shared some Pinch. We both choked on the 86-proof liquor—I, because of my fear and unfamiliarity with the stuff, and he, because of his raw esophagus.

“Drink as much as you can without puking,” I advised him.

As the strong spirits began to loosen me up, I looked at him with something akin to hatred.

“I’ll burn in Hell for this, you know.”

He smiled at me, with affection.

“No, you won’t,” he said shaking his head slowly, “Besides, I’ve been there for the last three months. Think of yourself as participating in my early release—for good behavior.”

I wished him good journey, and silently feared that he wouldn’t die, or that I would spend my life in the penitentiary at Angola. I injected the morphine as a “push” into his femoral vein, and held his hand as he hiccupped, gagged, and died.

There is not a day that goes by that I do not think of the Dying Man and wonder if I did right. There was no postmortem, and there were only rumors regarding the smell of booze on his body. No one suspected me—I was too straitlaced and had too much to lose. No one even noticed the tiny puncture in his groin, or if someone did, she remained silent.

Next day, after Grand Rounds, the oncologist swore when speaking among his peers about Dr. Jack’s death.

“How could his own wife bring the same damned stuff that shattered his health and incited his cancer to his deathbed? His tumors were responding to the chemo, but he just had to have his drink, and it finally killed him. People never cease to amaze me,” he ended bitterly, shaking his head.

I let her take the blame.

Paula Lyons, MD

Story Editor, Dr. Karen Marhefka

‎Friday, ‎November ‎3, ‎2006