For years my friends and patients have told me how surprisingly shocking the death of an elderly parent can be. We know it’s inevitable yet the finality is jarring. But knowing and KNOWING are two different things. So her son the doctor reacted just like so many others when my mother died unexpectedly last March at 86 after falling and striking her head. I found it hard to get my arms around the idea that my mother was no longer alive.
I received an outpouring of beautiful condolence letters and contributions but have only written a handful of thank you notes. My undoubtedly over-simplistic armchair psychiatrist explanation is that if I don’t write the notes then maybe she didn’t die. And I’m not alone in my behavior. My 90-year-old father, married to my mother for over 66 years, asked me a few months after her death if it was ok that he was pretending she was still alive. “Absolutely,” I replied. “That’s why God invented denial.”
My mother lived totally in the moment. She’d start to peel an orange and would say “at this moment this orange hasn’t seen the light of day.” Every morning she would look out the window at our breakfast table and say, “Good morning, dogwood tree.” More often than not, whatever she was experiencing was “the best ever.” The best ever sunset was the one she was watching. The best ever salad was the one she ordered at our last lunch alone together a few weeks before she died. Her best ever meal was the one she had just finished. She did not want to waste a single second, as was reflected in a hilarious essay she submitted to the New York Times upon turning 75. It was rejected; so here is the world premiere {link to NYT submission below}.
My wife had the idea to plant a dogwood tree on the top of the beautiful Vermont hill where we had sprinkled my mother’s ashes. Yesterday my family gathered under cloudy skies for the ceremony. One of my two sons sang a beautiful song he had composed using the lyrics of a poem called “Growing” that my mom had written when my three sisters and I were little.
Growing
Goodnight sweet baby and goodbye
I’ll see you as you are no more.
For dusk has settled in the sky
And you have wondrous dreams in store.
As you sleep, a magic hand will touch you
And you’ll grow more wise.
Tomorrow morning you’ll awaken
New and different in my eyes.
This morning my father admitted that he still finds it hard to accept she’s gone and sometimes imagines that “she’s just out shopping.” But we’re both starting to accept that we’ll see her as she was no more. This afternoon I’m going to start writing thank you notes in earnest. Well, maybe tomorrow.
***
Dear Editor:
I just celebrated my 75th birthday, and do you know what? I’m better than ever! Well, I guess you could say I’m stronger than ever. No, not in my muscles, which can be developed and maintained during regular workouts in the gym, but in my mind, which gets a daily ongoing on site workout. I now have the strength of my convictions, something I never had when I was young because in those days I always aimed to please, so that everyone would like me. I have now become much more assertive, more determined, more stubborn, and more aware of the passage of time, and as I calculate how much of it I have left, I have made a firm decision not to waste one moment of it.
With that thought in mind, here are some resolutions I’ve made to myself for the New Year:
1. I will not open unsolicited advertisements in the mail. This includes 10 million dollar lotteries and free trips to the Caribbean. Into the garbage they go!
2. I will not make dinner dates with boring people. This includes people who didn’t used to be boring but are now.
3. I will not put off doing things that I want to do.
4. I will not attend meetings out of a feeling of obligation.
5. I will not play singles rather than doubles in tennis or play an extra hour because I’m afraid to say no.
6. I will not ride when I can walk or walk when I can ride, depending on how I feel at the time.
7. I will not take part in long phone conversations with talkative people who are boring.
8. I will not dress up to go out if I feel like wearing a shirt, sneakers and jeans.
9. I will not shop ’til I drop. I never did and I certainly won’t start now.
10. I will not agree with someone unless I really do. I won’t be afraid to express my opinion.
11. I will hang up instantly on phone solicitors with no apology whatsoever.
12. I will remove the tag from each and every mattress that I own with absolutely no fear of penalty of the law, and when I make the bed I won’t always do hospital corners. Sorry, Mom!
13. I won’t be afraid to break a date if something better comes along.
14. I plan to make a lot of money selling something on Internet. Don’t know what yet.
15. I will not be intimidated by a surly maitre d’ or waiter. I won’t be afraid to send something back if it’s not to my liking, and if the rolls aren’t hot, back they’ll go.
16. I’ll squeeze the toothpaste from the top of the tube–so there!
17. I’ll watch every Seinfeld rerun, all Frasier episodes and all Woody Allen movies.
18. I will wear white before Memorial Day and after Labor Day if I want to.
19. I will always remember that health takes priority over everything, and I will guard it carefully.
20. I will keep smelling the roses and seeing, tasting, touching and hearing the world about me for a long, long time.
Senator Ted Kennedy’s death from brain cancer underscores the urgent need for more funding of basic cancer research. Despite the best efforts of a team of top doctors, Kennedy died 15 months after the diagnosis of a malignant brain tumor called glioblastoma. Over the past ten years, some progress has been made against this deadly illness and the silhouettes of some promising new approaches are becoming visible. But our treatment options remain woefully inadequate.
With over 560,000 cancer deaths each year, that comes to less than $10,000 in research spent for every cancer death. That simply is not enough money spent on a problem that strikes almost 1.5 million Americans each year and causes nearly one of four deaths.
Research for certain cancers is especially under funded. Earlier this year, I helplessly watched a dear friend and patient die from esophageal cancer, both of us knowing that only 22 million dollars each year – about $1,500 per death – was being spent by the NCI on the disease annually. One reason is that patients with esophageal cancer don’t have a strong advocacy group to push for their fair share of the funding pie. Lung cancer, which tops the list of cancer killers in America, only gets about $1,500 per death. At the top of the list based on research spending per death are cervical cancer (about $19,000), breast cancer (about $14,000) and brain cancer (about $12,000).
Click here for a chart that I compiled with the help of statisticians at the NCI that breaks down government spending on the top cancers.
Of course, there shouldn’t have to be a competition among cancer advocacy groups. There should be adequate funding of basic medical research to help discover the underlying cellular mechanisms that many cancers share and that hold the key to prevention, early diagnosis and effective treatment. But there’s not enough money for our young researchers. In 1980, almost 25 percent of first independent government grants went to scientists under age 35; that figure has plummeted to only 4 percent as the first-grant age rose from 34 to 42.
Faced with increasing competition for shrinking dollars, many of our best and brightest are considering other careers.
My cancer patients desperately need a bailout. The best way to increase our spending on cancer research responsibly is through health care reform. The Institute of Medicine has estimated that about 20 percent of the annual $2.5 trillion in health care costs is unnecessary. That’s $500 billion annually or 100 times the current budget of the National Cancer Institute. There could be no better tribute to Senator Kennedy or wiser investment in our own futures than to fix a broken system that threatens to bankrupt us while inadequately addressing one of our most devastating health problems.
For this week’s CBS Doc Dot Com, I take you behind the scenes to an edit bay at the CBS Broadcast Center in New York. I talk to Dr. Henry Friedman, an expert on brain cancer. He is co-deputy director of the Preston Robert Tisch Brain Tumor Center at Duke University Medical Center. In addition to hearing about the latest treatments for the disease, you’ll see the secret behind how we do long-distance interviews for the CBS Evening News with Katie Couric.
I noticed my use of the phrase ‘call it’ a few times recently. It is something I saw on American TV and not at all something that is common in my neck of the woods. The sort of scene that you would get in gray’s when the junior doctor is pumping the chest shouting ‘I will not let you die, dammit!’ while the senior doctors stand one side and instruct him to ‘call it!’ is pretty foreign to our way of doing things. I even got ragged a bit for using the phrase at all. I thought I’d relate a story from days gone by that illustrates this point.
It was the time of the taxi wars. Now taxis in our country are nothing like you might be thinking. They are fleets of mini-buses, quite often owned by people of questionable legal character. Occasionally rival groups try to take each other out (I mentioned this before here). But roughly at the turn of the millennium there was outright war. When the war came to Pretoria we saw quite a few of the victims, but neurosurgery got the most. A friend of mine was rotating through neurosurgery and this story came from him.
There had been a contact between two different taxi organisations. The casualties were streaming in. The neurosurgeon and my friend, his trusty lackey, were overworked and I think it had affected their sense of humour. So while they were getting another gunshot head ready for surgery and heard another four were en route, they were not amused. When the ambulances arrived the neurosurgeon said he wanted to go out and triage them in the ambulances before they were unloaded. And this is what they did.
The neurosurgeon looked at each patient in turn. The first three he told them to send into casualties for his attention. But the fourth…he took one look at the fourth and exclaimed;
“Vat hom weg! hierdie een is gefok!*”
My colleague laughed the next day when the newspapers reported: “On arrival at the hospital, one taxi driver was declared dead by the neurosurgeon on duty.” Fortunately they did not quote him verbatim.
The patient with a loving family, a job, good insurance and an abnormal test. Terrible.
When they come in, with their abnormal test (a sono in this case) from an outside place, from a doctor who sends them to your ED with ‘you need more tests’, it’s hard to keep the stiff upper lip. The family, well dressed and pleasant, just make it worse. I know what’s coming. I’d encourage them to run for the door, if I thought it’d help.
The sono usually says “…blah blah blahmass in theblah blah…further imaging is recommended…blah“.
While this usually isn’t a true emergency, let’s face it: the patient deserves an answer and their doctor has given up (or in) and has sent them to me. (And it’s not like I don’t know how to order CT’s, I do).
While waiting for the CT you imagine it’s all going to be nothing, unlike the ones before. Very very occasionally it’s good news, and relief all around.
The vast majority of the time that CT has been utterly horrible news for everyone involved. There are tears, and referrals, and ‘…I don’t know for certain, you need a biopsy, because diagnosis leads to prognosis…’ and I feel rotten for about a week. Unlike the family, for whom I’ve just unmasked Death, who get to have him as a constant companion.
I don’t know if it’s because they seem so normal, or I see myself in everyone in the room, or guilt. Dunno. But it’s horrible.
*This blog post was originally published at GruntDoc*
Sometimes before you are even called the sh!t has already hit the fan. The mopping up is not fun.
I was on call. As usual I was hanging around in the radiology suite (I spend a lot of my free time there sharpening up my CT scan reading skills. The radiologists even think I’m a frustrated radiologist, poor fools). The urologist phoned me. He had a nervous laugh. Most types of laughs of urologists I quite enjoy. But the nervous laugh I do not. He then went on to tell me about a patient he had been referred with possible kidney stone and severe pain, but on the scan they found a large abdominal aorta aneurysm. I quickly called the scan up on the monitor and sure enough there it was. The patient was mine.
There was an 8cm aneurysm. But just anterior to this there were signs of recent retroperitoneal bleeding. This was not good. The guy was just one step away from a fatal rupture. I phoned my vascular colleague in Pretoria who was unfortunately in theater but they assured me he would get back to me in about 20 minutes. Then another call came through.
“Doctor, the urologist says I must call you about his patient. He says it is now your patient. Something has happened.”
I knew I needed to run.
“I’m on my way!”
As I rushed through the ward I saw what must have been the family. They were all looking anxious and some had tears in their eyes. I rushed on. I needed to focus.
In the patient’s room it looked like well orchestrated chaos. Lying on the floor was a massive man who was as pale as a sheet. The casualty officer was intubating. A sister was doing CPR. The urologist looked up.
“Glad to see you! well then I am no longer needed. See you around.” And with that he walked out. Someone was trying to place a drip with little to no success. A large group of young student nurses were looking on with expressions ranging from shock to morbid fascination to excitement. I needed to take control. Only thing is I had seen the scan and I knew what had happened (when an 8cm aortic aneurysm ruptures into the abdomen it causes almost guaranteed instant death).
I told the nurse to stop CPR long enough for me to check for signs of life. There were none. She continued. I then did some basic tests to gauge brain stem function. There was no detectable brain stem function. I called it right there.
After a dramatic unsuccessful resus there is usually an eery silence in the room. Maybe it is a sort of respect for the departed or maybe it has to do with confronting one’s own mortality. I think it has a lot to do with thinking who is going to say what to the family.
“Are you going to speak to the family?” I asked the casualty doctor. I had to try.
“No! you are!”
“Great!” I thought. “I walk in on the closing act and I’m left with the hot potato.”
I took time to speak to the nursing staff, telling all those directly involved that they did well and just trying to somehow let the students know that it is ok to not be ok with death up close. Then I went quiet. I needed to focus.
The family had been taken into the sisters’ tea room. They then sent me in. The mopping up had begun.
I have spoken before about breaking bad news. Fact is, it is never easy and I’m not sure there is any easy way to do it. I try not to leave the family in the dark too long. Once they know I try to be as supportive as possible and to answer their questions as best as can. Usually I am struck by the human tragedy and I allow it to affect me as it should. Sometimes when I have been overcome by the relentless nature of my work I must stand back and observe. This was one of those times.
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For years my friends and patients have told me how surprisingly shocking the death of an elderly parent can be. We know it’s inevitable yet the finality is jarring. But knowing and KNOWING are two different things. So her son the doctor reacted just like so many others when my mother died unexpectedly last March at 86 after falling and striking her head. I found it hard to get my arms around the idea that my mother was no longer alive.
