Making Rounds and Oscar (2010) (14 page)

"Finally, the whole caregiver thing became exhausting. After all, they don't stop being ill to give you a break. Even though my partner understood, our relationship suffered. I didn't leave town for over four years. I became withdrawn and depressed. My blood pressure went up and I had a very hard time watching my mother disappear. I even started going to therapy to come to grips with everything. The therapy helped me understand that I needed help and that my mother needed to be in a nursing home."

"Did it make you feel guilty?" I asked.

"Initially, but I didn't feel guilty for long because it had to happen. In the end, though, once I got her into Steere House, I knew it was the right thing. We had a tough transition; my mother had been at another nursing home where things didn't work out.

"Ultimately, I was so happy to get my mother into Steere House. Aunt Barbara had also come down with dementia and was already living there. I was able to get my mother into the same room as her on the third floor. You know, my mother and Barbara lived together for sixty-eight years. They were apart for about ten years, but when they got back together at the nursing home, it was like they had never been apart."

Jack laughed. "The two of them loved their animals," he said. "I'm sure they thought that they owned those two cats. I'd come into the nursing home and find my mother in her room, but Barbara was always missing. I'd go hunting for her and find her sitting in some random room with one of the cats curled up in her lap. She'd light up and tell me that her kitty was here."

"What about your mother?"

"Oh, she was the same. There were times when I thought that my mother no longer recognized me, but she would always light up when one of the cats was in the room. Both of them. I would put one of the cats on their beds and they would just smile.

"The strangest thing is that my mother and aunt eventually forgot almost everything. They couldn't remember my name, where they were, or who they were. Yet those feelings--well, they remained. It was the same if there was a baby on the floor or if a certain tune was playing on the radio. Even in the end, they would simply light up."

"So, was Oscar there at the end?" I asked.

"The nurses tell me that Oscar was at Barbara's death. He came in a few hours beforehand and she died shortly thereafter. I wasn't there when my aunt died, but I can tell you what happened to my mother with Oscar."

Jack grinned.

"When Oscar was just a kitten, I used to bring him into my mother's room and put him on the bed. He would stay there for a minute or two, and then he would leave. You know what kittens are like."

Actually, I didn't.

"It was great for my mother, but he never stayed long. During the last week, when my mother was unconscious, Oscar would come into the room, look around or jump onto the bed for a moment, and then leave. On the night my mother died, the night nurse called me in to see my mother. She told me my mother wasn't doing well and that I should be there. When I got to the room, the lights were dim and they had started doing aroma therapy. I went to the bedside and was stunned to see Oscar lying there on the bed, curled up next to my mother. When I sat on the bed, he didn't budge; he just sat there purring."

Jack now wore a look of befuddled amazement.

"Seeing Oscar there at the bedside, I looked at my partner of eleven years, who was always there for me and my mother, and told him we were not leaving. As I said, my mother had this unique connection with cats and I knew this was the way she was going to die, with a cat at her side. Two hours later, my mother took her last breath. Oscar never moved until she died. Then he got up casually, like nothing had happened, and left the room."

We sat in silence. I was picturing Oscar. I bet Jack was too.

"I suppose my mother would have been happy to know that she died with one of the critters she loved the most. But to tell you the truth, all I felt was relief. I'd like to tell you that I felt horrible when my mother died, but I didn't. I think Ronald Reagan's daughter said it best for all of us when she called her memoir of her father's Alzheimer's
The Long Goodbye
. Every day I miss the mother I had sixteen years ago, but not the person she became. It was like watching a kid, but having them unlearn everything they knew."

I thought back on my conversation with the Scheers, who had voiced the same complaint. It must be like watching a film of a person's life run backward, I thought, except the person doesn't get any younger.

I asked Jack if he had any last thoughts about his experiences. He considered for a while before responding.

"You have to learn to love the person they become and find moments of happiness in the little things," he said. "That's why those animals at Steere House are so important. Dementia is all about comfort and distraction. I always felt okay about leaving my mother and Barbara because they had excellent care, each other, and they had their cats."

Standing at the doorway as I took my leave, I shook Jack's hand. Before I could go he offered one last thought.

"You know, Oscar the cat was not just a distraction for my mother," he said. "He was my distraction as well."

CHAPTER EIGHTEEN

"It always gives me a shiver when I see a cat seeing what I can't see."

ELEANOR FARJEON

ONCE AGAIN, I HAD GONE OFF IN SEARCH OF ANSWERS
and had come back with only more questions. Regardless, my visits were providing me with fresh insights into the disease that was afflicting so many of my patients and their family members. In a way, they were making me a more empathetic doctor.

I thought of Mary--my sounding board in this process, my confidante--and what made her so good at her job. I'm sure so much of her caring and compassion is innate; still, I also knew that she'd been through a lot.

This former beauty queen--she had been Miss Cranston, Rhode Island--had married the man of her dreams, only to find herself in an abusive relationship. When she reported him to the police, he killed himself in retaliation.

Having lived through that and singly raised two kids to college age, Mary was a tough customer who relentlessly focused on the positive. She was still full of surprises. Once, after she had pointed out the house where Talking Heads used to play, back in their days as students at the Rhode Island School of Design, she casually announced, "I used to go out with David Byrne."

As I said: full of surprises.

But the sight of her and the bleak expression on her face tempered any enthusiasm I felt and put my sense of wonder on ice.

"What's going on?" I asked when I found her frowning in her office.

"Nothing, David. It's just a bad day."

Mary stared off into space. I said nothing but didn't take my eyes off her. Eventually she opened up.

"Well, it turns out that the state of Rhode Island in its infinite wisdom isn't giving us the same amount of per-patient funding this year as they did last, and the administrator is threatening more cuts."

Every year, it's the same thing. The state asks us to do more and more with less and less. In a bleak economy, nursing homes are easy targets for bureaucrats looking to trim the budget anywhere they can. It's not like our patients line up outside of their legislator's office to protest.

Mary's news hit me like a wet blanket and I sat down in my chair with a thud. I knew that she was upset. Jobs were at stake and Mary was a perfectionist. She didn't like the idea of potentially compromising the care of her residents.

"So, who are you here to see?" Mary asked, attempting to put a smile back on her face.

"I wanted to check on Ruth. How's she doing?"

"Much better, actually. Her delirium has improved and she's eating again. I even saw her husband walking down the hallway with her earlier today. They were holding hands and it was really quite cute."

Mary's mood seemed to lift but the moment was short-lived. Her expression turned bleak again.

"Have you seen Saul?" she asked. It was almost a whisper.

"Not since shortly after he was admitted to the hospital," I said. He'd been over there for several weeks now, getting progressively worse.

"His daughter called today. She didn't sound so good. I guess he's in the intensive care unit now and not doing well."

The news wasn't surprising to me. Saul had been close to death when he left the home and I knew then it was just a matter of time. I looked off down the hallway in the direction of his old room.

"I wish..." I started but didn't finish my statement. Truthfully, I didn't know what I wished anymore. Saul had been pretty explicit about his wishes earlier in life--he wanted everything done, he kept saying. Yet his circumstances had definitely changed. Somewhere in the back of our minds, I know that most of us have a vision of how we would like to die. I was quite certain that Saul's vision didn't involve his current condition. But it didn't matter. The die had been cast.

"I know, you wish she'd have left him over here on hospice where Oscar could take care of him."

"I think it has less to do with the cat and more to do with the care that you and your staff provide up here. But yes, if I were in Saul's condition, I know I'd rather be here--cat or no cat!"

Invoking Oscar finally brought a smile to Mary's face. "Speaking of our friend, why don't you go take a look in Saul's room?"

I hesitated. I knew he wasn't there and I had come to see Ruth, and still felt that I hadn't been of much solace to Mary.

"Go on," she said.

I walked down the hall toward Saul's room. On the way I passed Ruth and Frank walking together, hand in hand. I said my hellos. Ruth greeted me with a warm smile.

"You're looking much better, Mrs. Rubenstein," I said. Though I sensed some recognition, I didn't expect her to respond, so I asked her husband, "Is she eating again?"

Frank smiled from ear to ear. "Like she's just come off a hunger strike!" With that, he vigorously shook my hand.

I may have actually smiled. I knew it was a temporary victory, but I was happy for them nonetheless.

I WASN'T QUITE SURE
what I expected to see in Saul's room. It was dark and his belongings were laid out meticulously in preparation for his return. His bed had been carefully made; the comforter was drawn up above his pillow. Then I saw something move. In the dim light I recognized the shape of a cat. Oscar had started his vigil without the patient.

On my way over to the hospital, I thought about Barbara's decision to keep her father alive at all costs. Who was I to judge? It was so difficult to make that final call, to allow your parent or loved one to slip away. Maybe it was even a little unfair to burden a family member with such a terrible decision. Saul had insisted that he wanted everything done--back when he could still insist, back when he knew who he was.
To each his own,
I thought as I rode the elevators to the ICU, but I knew deep inside that I'd have chosen the cat.

There's little privacy in the intensive care unit. The doors to the rooms are almost always open wide so that nurses and staff can monitor their sick charges more effectively. These days the majority of ICU patients are older--in their eighties and beyond.

Room 19 was no different. A frail, graying man lay asleep in bed. A blue heating blanket covered much of his torso; it looked like a float that my son or daughter would use in a swimming pool. The blanket, filled with warm air, provided needed warmth to a body unable to fully generate its own heat. I barely recognized Saul. The nameplate on the chart confirmed his identity. Approaching his bed, I could see that a three-pronged intravenous line had been inserted into his neck. A dialysis machine was parked at the bedside. It was an ominous development for a man who never had any problems with his kidneys.

"I'm Dr. Dosa, Saul's primary care doctor," I said, introducing myself to the nurse who was standing in the corner charting at a computer. She acknowledged me with a brief nod before returning her attention to her notes.

"How's he doing?" I asked.

"Not good. He's still got low blood pressure on dobutamine and dopamine. His kidneys are failing, and the doctors are thinking about starting dialysis." The nurse shrugged. "We're doing everything we can."

I walked over and looked at the IV medications hanging from poles positioned above his head. He was on three antibiotics, all with expensive-sounding names: linezolid, Vancomycin, and ceftazidime. None of these medications had done anything thus far to threaten the bacteria in his bloodstream. The little buggers were winning and it was only a matter of time.

"The cardiologists are coming up here this afternoon to perform a transesophageal echocardiogram. They think his heart valves are seeded with bacteria," the nurse said, looking up from her computer.

I shook my head. Would he have wanted any of this? Certainly the trip to the hospital had been reasonable. But life events often get in the way of good intentions. Within a day, Saul's breathing had become labored, and his blood pressure bottomed out. Phone calls were made to the family. "He's hypotensive and we're going to need to put a tube in his lungs to help him breathe."

Looking at Saul, I realized he would now have a probe stuck down his esophagus in order to determine if his heart valves were also involved. Yet it wouldn't change anything even if the test proved positive. He certainly wasn't a candidate for surgery in his current state.

"Are you sure that all this makes sense?" I asked the nurse.

She shrugged. "Talk to the ICU doctors. Personally, I don't think so, but no one ever listens to me."

I smiled at her. "Me either."

My patient was way past autopilot now. No one would stop to ask if any of this made any sense. His breathing was labored, so they intubated him. His blood pressure was low, so they put him on medications. His kidneys were failing, so he was being considered for dialysis. Each treatment, procedure, and test made sense in the context of the latest information, but the big picture was absent. There was no consideration of the why; instead it was
full steam ahead!
I left Saul to his nurse's care and went in search of his intensive care doctors.

"Will it make a difference?" I asked the physician I found.

"Probably not. I think he's dying, but his family wants it done."

I returned to the front desk to call Saul's daughter. She answered immediately and I updated her about her father.

"The doctors here would like to put a tube down your father's throat to see if his heart valves are infected. Even if the test turns out to be positive, I'm not sure your father's poor condition will allow us to do anything to change his circumstances."

"Doctor, he wanted everything done."

"His circumstances have changed, though, Barbara."

"Everything, Doctor. Everything."

THE CALL CAME
just after midnight. I got up to answer the phone, rubbing the sleep out of my eyes.

A young physician offered his condolences. "I'm sorry, but I just wanted to let you know that your patient Saul Strahan died earlier this evening. We tried CPR but we couldn't get him back. We did everything we could."

"Did you call the family?" I asked.

"We called his daughter. She took it really hard, but she's in with him now."

I told him to offer her my condolences and thanked him before hanging up the phone. I stared off into the darkness, thinking about Saul. I said a quick good-bye to him in the night air and then thought about his daughter. Did she get a chance to say good-bye? Probably not. I wondered if his minister had been by.

"What's wrong?" my wife asked, half asleep.

"My patient just died."

She muttered something unintelligible. In my business, these sorts of calls are not infrequent.

I settled back into bed, but found it difficult to fall back to sleep. In my mind, I pictured Oscar looking out of the window from Saul's room, perhaps gazing in the direction of the hospital across the street. I wondered if he knew. I am quite certain he would have been there, curled up next to Saul, had he stayed at the nursing home. In the end, all the procedures, tests, and treatments didn't make a difference. It was just his time. We all have choices about how we die, and some deaths seem better than others. I told myself that at least Saul was at peace. He'd moved on, whatever that might mean. I just wished the transition had been better.