Editorial

Death Is a Crafty Old Friend

Copyright © 2008 Society of Hospital Medicine

I will never forget her first words to me: You mispronounced my name.

I remember stopping short, awkwardly looking down at the emergency room chart in my hands and wondering how I could have mispronounced Mrs. Wells. I'm sorry, how should I say your name? I asked her.

Kitty.

Ah. Miss Kitty? I tried. This is, after all, Virginia, and octogenarians here are renowned for their adherence to social niceties.

She shook her head, her frown showing just how hard she was working to be patient with me. Miss Kitty was a character on Gunsmoke, she told me. Well, actually, she was lecturing me. I have never had red hair, I don't own a saloon, and I sure as heck don't have Marshall Dillon to keep me company. Darn my luck.

She was my seventh admission that afternoon, with at least 2 more to follow, but I found a smile for her and started into my usual routine. So, what brings you to the hospital today, Kitty?

I was hoping to meet a cute young doctor, she told me. And I think I succeeded.

This was clearly not going to go quickly. We'll deal with your poor eyesight later. What about the shortness of breath that the nurse wrote on your chart? I did not even mention the audible wheezing or the pursed‐lip breathing I had heard from outside the curtain.

Oh, that's just a ploy, she lied. To get to the meeting the cute young doctor part.

In glancing at her fingers to look for clubbing, I noticed the golden band and the tiny diamond ring, both of which looked huge on her knobby fingers. Kitty, I gently scolded her, I don't have time to deal with jealous husbands.

She laughed as she absently twirled the rings around her finger. Carl won't mind, she told me. He's been dead 14 years now.

But you still wear his rings, I pointed out.

He brought this ring with him when he came back to me from France after the war, she told me, straightening the tiny diamond on her finger. It was all his private's salary could afford, so he gave me the ring and a magnifying glass, and he told me to never look at the ring without using the magnifying glass.

No, this was clearly not going to go quickly at all. But I was pretty sure I was not going to mind.

Over the next 4 days, Kitty and I got to know each other fairly well. Her chronic obstructive pulmonary disease exacerbation improved to the point that I could send her home, and she begrudgingly accepted my recommendation of oxygen at night.

Over the next 2 years, I admitted her 7 more times; to my frustration, this meant that she was seeing me more regularly than she was seeing her primary care physician. After her third admission, I found myself having to convince her that it was time to start using her oxygen continuously. When she came back for her fourth admission, I noticed the cane at her bedside. Are you having trouble walking now, Kitty? I naively asked her.

Of course not, she shot back quickly. This is just in case I see a man I want to get a closer look at. I just hook him around the ankle and pull him in.

That discharge was to a skilled nursing facility because she had no family and no one else to care for her. After her 3 months of skilled benefits, she transitioned to long‐term care, and the next time her emphysema acted up, she thanked me for the introduction to all those handsome gentlemen. On each day of that admission, she asked when I was going to let her out of the hospital. Each day, she made sure that I knew, meant missed opportunities for her to be able to figure out which of the male residents was meant to be Carl's successor.

Her sixth admission was for pneumonia, and we nearly lost her. I am still convinced that it was nothing more than her self‐described abundance of piss and vinegar that pulled her through.

When the emergency room called me less than a month later for her seventh admission, I knew that Kitty and I were getting awfully close to the end of our relationship. She was tired and weak and smaller even than she had been just a few weeks before.

I admitted her to the intensive care unit for the first time on that admission, and I made the mistake of telling her that it was because with her somnolence and with her wish that she not be intubated, I was flirting with the idea of bilevel positive airway pressure (BiPAP) ventilation. She managed to find enough wind to tell me that I should save all my flirting for her.

Three days of antibiotics, frequent bronchodilators, steroids, and as much BiPAP as she could stand did not net us much improvement. On hospital day 4, the intensive care unit nurse caught me before I knocked on Kitty's sliding glass door.

She wants to go home, Lucy told me.

We're working on it, I reminded her.

Lucy shook her head. No, she said. Home with a capital H. Heaven. Lucy relayed the conversation that Kitty had had with her. The one that my old friend had not had with me.

The one that I should have had with her.

I closed Kitty's door behind me and sat down at her side on the bed, noticing how she was drawing each breath as if she had to pay for it.

Lucy told me about your conversation, I said quietly, once Kitty had finally opened her eyes and found me. No more BiPAP, I understand. She nodded. I waited for her to say something more, but she did not. Why didn't you tell me, Kitty? I asked her gently.

She laughed; her laugh was a short, tired little thing that died in her throat. She reached from under the covers to pat my hand. I suppose, she said, that I didn't want to let you down. You always seem so proud of yourself when I come in here, gasping and coughing, and you get me well enough to go back home. She paused to blow off some CO2 and find a sad smile for me. Time to let me go, she told me. Let me be with Carl again.

We talked for quite a while. Well, actually, I did most of the talking. She did not have the wind for it. I admitted to her just how embarrassed I was that she had had to bring this up to me. I have for quite some time been rather comfortable with the notion that death is not the worst thing that can happen to a patient. It was Dr. Tom Smith, at the Medical College of Virginia, who first introduced what was then a wide‐eyed, idealist medical student to the concept of a good death: snatching a victory for compassion from the jaws of a medical defeat.

Therefore, at Kitty's insistence, there was no more BiPAP. When her breathing became labored, we gave her just enough morphine to take the edge off her air hunger. Rather than round on her in the mornings, I simply sat with her.

I would like to say that I was with Kitty when she died. It would bring the story full circle and give our relationship a clean beginning and a clean end. It would be good fiction.

However, it would also be a lie.

Lucy met me at her door again, just 3 days later, and told me about Kitty's quiet passing, in her sleep, just an hour before I had arrived for rounds.

I sat at Kitty's side one last time, holding her now cold hand. She was smiling.

At least, that is how I intend to remember that moment.

The bed sagged just a bit on the other side as I realized that Death had joined me. For those who have not had the pleasure, the part of Death is played by Gwyneth Paltrow.

We sat in silence for several minutes, Death showing me the patience that she had once told me she had.

I rarely see it.

How is she? I finally asked.

Better. She and Carl are catching up a bit. I nodded. He's giving her hell for losing that magnifying glass.

I could not help the smile. Carl was one lucky man.

She says thank you.

Whether it was true or not, it was nice for Death to say it.

She let me have a long stretch of silence before she felt the need to ruin our tender moment. You have any other business for me?

I growled a warning, and she smiled. That was a joke, Doctor. Lighten up a little, would you?

She turned to go, but I stopped her. Hey, I found a great quote for you. The last time that we had chatted, she had been lamenting the plethora of love lines and the paucity of good death ones:

Because I could not stop for Death,

He kindly stopped for me;

The carriage held but just ourselves

and immortality.

Emily Dickinson, I told her.

Huh, she said, frowning and doing that thing with her eyebrow for which Gwyneth gets paid millions. Wonder why she thought I was a he?

Acknowledgements

I thank the editors of the Journal of Hospital Medicine for considering this submission. This is a fictionalized account of a true patient experience. The patient in question has passed away, but while she was alive, she and I discussed many things, including my writing, and she actually asked that I write about her some day. This is the fulfillment of my promise to her.

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