Physicians are commonly exposed to events more unusual and heart-rending than the most inventive Hollywood screenwriter could possibly devise. There are days when I think back over the stories patients have told me, the crises and turning points I have witnessed, and I can hardly believe they actually happened. One such episode took place several months ago on one of our hospital wards. Let me say in advance that you will find this story hard to believe. But I vow, with one hand on my Harrisons’ medical textbook, that what you are about to read did actually take place. Exactly as I will describe it.
Mr. Gentry was an 86-year-old man with Alzheimer’s, whom I had followed for many years. Other than his confusion, which had become increasingly problematic, he was in reasonable health, his diabetes well controlled. His ability to remember my name on periodic office visits had diminished significantly of late. His wife and large family were very attentive, making it possible for him to remain at home much longer than most patients with advancing dementia.
It was in the fall that Mr. Gentry suddenly became much less responsive at home. After several hours, his family brought him to the ER. He was promptly diagnosed with sepsis, probably of urinary tract origin. Antibiotics and fluids were started, and the ER doctor asked the family about code status. The family was entering uncharted territory. Despite a number of discussions of this issue over the years at his clinic visits, and despite the family’s awareness that Mr. Gentry’s quality of life had declined steadily the last year or two, they were unwilling to place him on DNR (do not resuscitate) status.
“Let’s give it a few days and see how he does,” was the request of the wife and children.
Over the next three days, Mr. Gentry slid inexorably downhill. His kidneys started failing. He did not respond well to the antibiotics. He became less responsive. His only interaction with his family was moaning precipitated by vigorous stimulation. Occasionally he showed random eye movements, but he did not make meaningful eye contact with anyone. He did not speak.
I spent much time with the family trying to help them cross the threshold, to reach the understanding that our care was futile, and we were only prolonging his suffering. As the days went by, increasing numbers of family members came to town, holding vigil in Mr. Gentry’s room. In-laws, cousins, and grandchildren from all corners of the country appeared. It was obvious that Mr. Gentry was a respected elder in his extended family. It was also very clear that the family remained uncertain and insecure about withdrawing any level of care.
One week into his hospital stay, we were still making no progress whatsoever. I headed over to the hospital for yet another family conference late on a Friday afternoon, after my clinic had ended. I knew there were roughly two dozen people waiting, and I was determined to once and for all convince the family, as humanely and compassionately as possible, that Mr. Gentry himself would surely not want to be kept alive like this. If his faculties were intact, he would want things stopped. By clearly taking the responsibility off the family’s shoulders, and placing in on the patient’s and mine, the family would feel less guilt and would finally let go. I had gone down this same road many times with many other patients, and I felt my skills in navigating this course were excellent.
As I trudged down the back hallway, looking at my watch, I was thinking of all the other things I would rather do at 6:00 pm on a Friday night. Well, I had no choice. Besides, tonight was the night I would finally make the breakthrough Mr. Gentry needed.
When I reached Mr. Gentry’s room, the clan awaited me. There were even more family members present that I had thought, ranging in age from several in their 80’s to a handful of teenagers. I checked Mr. Gantry over. No change. He was unresponsive. No reaction to verbal or physical stimulation. I turned my back on him, sat on the edge of his bed, and launched into my spiel, addressing the family before me, spilling out into the hall. As I prattled on, I felt good about my powers of persuasion. Tonight, I would finally convince them. In fact, for the first time I now saw some heads nodding in agreement as I discussed the futility of pursuing aggressive measures at this stage in Mr. Gentry’s life. Several family members began to sob openly, but this did not deter me. I knew that grieving is a necessary part of letting go.
Then, as I was nearing my wrap-up, a couple of the teenagers in the room began to chuckle and looked past me at Mr. Gentry. The sobbing from some of the older relatives had quickly stopped. The entire family was now looking past me at Mr. Gentry.
This stopped me cold. I turned around to see the source of this abrupt change in the family. There lay Mr. Gentry, just as before, except for one thing. His left arm was extended stiffly out towards me, his fist clenched, and his third finger pointing to the ceiling. Demented, unresponsive Mr. Gentry was giving me the bird.
A nephew who was next to Mr. Gentry looked stunned and embarrassed. He grabbed his uncle’s arm and forced it down onto the bed.
I turned around to face the family, and to a person, there eyes were large and their mouths were gaping open. For myself, I was speechless. What words could I possibly speak at this moment which would have any meaning or significance? No, there was not point in trying. I had been given my comeuppance.
During the subsequent awkward second it was hard to know who was more uncomfortable, the family or me. I cleared my throat, stammered out that perhaps it was best to let things settle through the weekend, and discuss things again on Monday. Everyone present readily agreed. Perhaps even Mr. Gentry.
I hiked the quarter mile back to my clinic, thinking all the while about the wondrous durability of the human spirit. Was Mr. Gentry’s salute a random movement, like his unfocused eye movements? Or was it a defiant rejection of my efforts to get the family to withdraw support? Was he telling me he still wanted a little more time before he moved on? Maybe on some deep level, far below his cortex, in byways of the brain we have never understood, Mr. Gentry wished to have a few more days with his family, basking in their love and warmth.
Or perhaps it was all of these combined.
Mr. Gentry died a few days later, his family by then ready to accept his passing. And, evidently, Mr. Gentry himself was finally prepared to go.
(January 2000)