January 25, 2010

USA: It was hard to let go of Mr. Martinez

. LOS ANGELES, California / Los Angeles Times / Living / January 25, 2010 By Mark Morocco Whether you're a fancy, shiny-shoed cardiologist, a stuffed-animal-squeaking pediatrician or a grungy post-night-shift ER doc, from time to time, all doctors want to kill their patients. Some are too demanding and difficult, some are too time-intensive and some just refuse to believe what we tell them. Mr. Martinez was all three, a mercurial patient trifecta who was a sure bet to drive me crazy. The final straw was that every card in my wallet -- bank card, credit cards, driver's license -- was wiped clean when I rushed to rescue him from an anxiety attack in the MRI. Related Study: Doctors delay communicating end-of-life care issues with terminally ill patients I wanted to kill Mr. Martinez all the way across Los Angeles, from the ATM near my house to the checkout line at Ralphs. Not your bureaucratic, passionless, Sarah Palin-invented "government death panel" killing, but a personal, pillow-wielding, "Cuckoo's Nest"-style snuffing out of Mr. Martinez's candle by the only person left in his life who was still willing to talk to him. I hit critical mass in the DMV line at the three-hour mark. Because the big magnet had erased my identity, I couldn't buy a gun if I'd wanted. Like me, my fantasies for Mr. Martinez would have to wait. But his cancer wouldn't. It had set up ugly outposts all over his lanky 6-foot-4 frame and was now in his brain. He delighted in telling me that this was his fourth cancer and he'd beaten the disease every time. But after a last chemo-and-radiation cycle, a long line of doctors had spent hours telling him that his days were truly numbered and that this time he would not win. He threw them out of the room, and that is how he became my patient. I was the "sub-intern" -- a few months from graduation -- so when Mr. Martinez exasperated the last of the "real" doctors, they passed the hot potato, and the responsibility for his end-of-life care, to me. With the latest academic ideas on hospice care still fresh in my mind, I knew exactly what to do. I would control his pain aggressively and arrange for care in some place where he could "die with dignity." If only I could get him on board with this plan, my job would be easy. Obvious Lesson No. 1 in medical school, however, is that there is nothing easy about "treating" death and nothing simple about making plans for it. Armed with miracle machines and genetically built drugs, doctors promptly forget this lesson in our focus to save our patients or to at least let them live another day. Yet death waits for all of us, and, like Mr. Martinez, we usually just don't want to talk about it. "What's to talk about?" he'd yell at me. "Go away!" His pain was horrible, and the cancer was making him crazy. He could be sweet and funny or angry and defiant. Sometimes he just sat silently, eyes closed when I checked on him each morning and afternoon. I never knew which Mr. Martinez would be in the bed. He spoke Yiddish-accented Spanglish, the result of a long life watching a city evolve. He had bought the store where he got his first job as a boy and ran it for almost 60 years, outliving a wife and two children, owning ("free and clear!") a small house that was falling apart as he became less able and unwilling to accept or trust help from "outsiders." He pushed away gardeners, plumbers and neighbors, so doctors were easy -- and a med student? I didn't need a Yiddish dictionary to look up putz. Two or three times a day, I'd adjust his pain medication and start a conversation to bring up the subject of his death. Usually he would throw me out, but sometimes, when his pain was less and his mood better, the conversation would turn. A little philosophy, then some history . . . I learned that before Cesar Chavez Boulevard, there had been Brooklyn Avenue. Mexican kids, Russian kids, Jewish kids, ice cream parlors, movie theaters, the first "Cedars" hospital, a couple of wars and street cars to the beach! It made me, a displaced New Yorker, feel a bit more at home in Los Angeles somehow. If I tried gently to steer the conversation into the present, he'd throw me out of his room, the spell bro- ken. The nurses enjoyed watching this battle of wills, but eventually Mr. Martinez won and I gave up on my mission. If he wanted to die in a hospital, fine. Visits with him became something I looked forward to during my day. When he was awake, I would enjoy his stories, and, when he wasn't, I could simply sit for a minute or two, watching him sleep under the blanket of dilaudid that kept him from the pain. Sometimes doctors are surprised when we find it hard to let go. It's too simple, I think, to say that we feel like we've failed to win against disease and death. Handing off becomes a personal loss, even when it's to the patient's family or to a hospice professional, even when there is plenty of time, the right planning and everyone is in agreement on what to do next. So we delay, or give up, or wait for the disease to make the decision and for death to have the final word. But it is still a shock how hard it is for both doctors and patients to make the decision to let go. Sometimes we never do. And so my month with Mr. Martinez went on until one morning when I found his room empty, the bed stripped bare and the blinds opened to a blazing blue East L.A. sky. The nurse read my face, and lied: "Your friend said goodbye. It was a good death." Her clipped Filipino accent gave the news a hard finality, washing away soft Yiddish whispers in the February sun. His death left my days in the hospital simpler, but poorer -- just like his boyhood, years ago. Morocco is an associate professor and associate residency director of emergency medicine at UCLA Medical Center and was the medical supervisor for "ER." [rc] health@latimes.com Copyright © 2010, The Los Angeles Times