The first thing that I noticed was her eyes. They were the coolest of blues, bright under the pale fluorescence from the lights above. A reminder of her strong Irish roots, my dad would always say. However, my grandmother’s actions sufficed in validating her heritage: she was stubborn and strong, never one to yield in protecting her family as the matriarch of our clan. I was told that she faced many obstacles along the way. Afterall, she raised my father and his siblings while Pop was serving in Vietnam. Following many years of child rearing, she was happy with her life, comfortable and at peace. She let her guard down, and then she started to forget.
At first, it was little things: a bill, a pill, some keys. Initially, we cut her some slack; she was 75 after all. “This is normal,” we would say to each other. Slowly, mistakes and slip-ups gave way to confusion and disorientation, with questions of “what do you call this thing again?” becoming “who are you?” Gram had met her match with Alzheimer’s.
Sitting in front of her now, surrounded by the sterile walls of her nursing home, bombarded by a cacophony of beeps from alien machines, I was fixated on her eyes. Maybe I was looking for something. Perhaps the old Gram was somewhere in there, dressed in the red velvet blouse she would wear to family Christmas, smiling on the couch by the tree as we opened presents. I searched for signs of recognition, a comforting glance or a twinkle in her eye that said “yes, I know you, you are my grandchild!” Just as I was looking for an inkling of hope in her eyes, she was searching mine for the reassurance that, at the end of all of this, she would be okay.
At the time, I was too young to understand exactly what was going on. I saw my grandmother when visiting hours allowed, but I was blithely unaware of what had been taking place behind the scenes: discussions of if Pop could care for Gram independently at home; searches for a nursing home; decisions concerning goals of care and end-of-life planning. I was blind to the amount of work required to prepare for my grandmother’s peaceful passing, the strides that were made to ensure that, despite the circumstances, she would go “the way she would have wanted to.” I simply offered a hug to my father and a shoulder to my mother when we finally received the call that she had breathed her last.
Many years later, I found myself on the 17th floor of Bellevue Hospital, peering into a set of eyes that were all too familiar; however, the face that wore them this time was different. Around us were similar pale walls; between us, similar barriers. With my grandmother, it was her mutism; with my new patient, it was her Polish language. The patient’s blue eyes took me back to the nursing home, communicating fear and confusion.
Her chart said that she had suffered a fall at home; her CT scan revealed that the fall was just the tip of the iceberg. Her brain was atrophied and her sulci enlarged, corroborating reports from family that their grandmother’s memory had been declining. In her chest, a mediastinal mass was encasing the superior vena cava. In an 88-year-old woman, cachectic and bearing the scars of a previous mastectomy, the likely culprit was clear: cancer. To our patient, demented and disoriented, it was simply a word: “I am old, and old people get lumps.”
Our team needed to know how to proceed, and it was clear that she did not have the capacity decide. “Would you feel comfortable breaking this news to her family?” The resident’s words resounded in my ears. Comfortable? I certainly was not. However, I was faced with a responsibility unique to the medical profession: the vocation to serve as a healer and guide, to deliver news both good and bad to those facing the uncertain. This is what had drawn me to medicine. This is why I am here. So, I picked up the phone.
In my conversations with my patient’s family, I learned a lot about her life. Much like my grandmother, she was the cornerstone of a large family. Strong-willed, perseverant, and at times stubborn, she lived life cherishing the little things: making pierogis for her great-grandchildren, Sunday mass, trips to the market with friends. She never longed to return to Poland; she had her own close-knit group in Brooklyn. She loved living in Greenpoint; despite her disorientation, hearing the word made her smile widely. “Greenpoint, tell me how I know Greenpoint!” Although struggling to understand its true meaning, the word meant something to her. It meant peace, familiarity, and comfort. Far away from this strange, foreign place.
As I learned more about my patient, the conversation concerning goals of care became less scary and more fulfilling. It was clear to both me and her grandson that she would not benefit from further workup of her mass. The risks of biopsy, the toll of treatment, the long hours spent in and out of the hospital; none of this fit with the future she had envisioned for herself. She simply wanted to spend her last days at home. We both decided that she was the perfect candidate for home hospice. Her pain would be managed, and the quality of her remaining time would be optimized. She would be cared for in a way that reflected the strength and dignity with which she imbued her life. Although difficult, we had made a decision.
In discussing end-of-life planning for my patient, I realized that I had become the healthcare professional on the other end of my Pop’s phone calls many years ago. I was the person called when advice was needed, I was the guide present when decisions became tough. I took responsibility for my patient, and for the first time, I truly felt like I was a provider. Strangely enough, it was the medical decision not to treat that made me feel this way.
Recently, I read an interesting statistic: in my career as a physician, I will care for approximately 20,000 patients, address 500,000 problems, and write about 240,000 prescriptions. However, regardless of how many tests I order, medications I prescribe, or procedures I perform, this experience taught me that quality care is not always synonymous with more care.