Instead of dying as expected in 6 weeks, Michael began to fill out and pink up. He ended up outliving his prognosis by many months. I vividly remember the day he arrived at New Hope. It had been a long frustrating day there. New Hope was the unintentionally ironic name for the facility that we who saw patients there actually called “No Hope” or “Calcutta of the north.” It is the nursing home of last resort—one of the few that still has a smoking area. In this particular smoking area the lines are blurry between medical and recreational marijuana. Cigarettes are sometimes rolled out of loose-leaf paper and there is a designated “smoking aid” to supervise the smokers who lack the safety awareness to smoke without supervision. We called it Calcutta because a day at New Hope made it clear that there was no need to travel far to find an impoverished, underserved population to care for.
We took turns joking among ourselves about which one of us had the current honor of being the provider of last resort. I had been attending patients there once weekly for the last five years by my own choice. It was a slam-dunk in the “right livelihood” step of the Noble Eightfold Path to Enlightenment and far more interesting than tinkering with insulin dosages in the well-to-do, well-insured population.
However, the day of his arrival had been a particularly emotionally exhausting day. I was not at my best—not my highest self—when I heard about the late afternoon admission coming. The papers said he was coming for comfort care. He had pneumonia, metastatic cancer, a daily IV heroin habit and was homeless. He had pleaded successfully with the social worker at the hospital that he didn’t want to die on the street and was therefore en route to us.
Feeling like a hypocrite (in the other part of my job I teach students to be compassionate, caring physicians) I stood waiting for him with a fistful of papers in hand thinking, “Here we go again, I am so through with manipulative addicts.” Thank God, at least he was dying, so that the inevitable negotiations over pain meds would be brief and the need to connect less imperative.
So, fistful in hand, I performed a fairly perfunctory admission when he arrived.
“Are you coughing?”
“Short of breath?”
“Only when I cough.”
His physical exam revealed numerous scars and divots and skin grafts—maps of previous abscesses. It was also notable for the amateur black ink of poorly executed prison tattoos—maps of other ground he’d charted.
More by habit than by any shred of human decency, I ended with “So, is there anything else that you would like me to know about you?”
I felt my armor click a little tighter as I heard “Doc, I hurt all over, the methadone isn’t holding me—I think I need Dilaudid.”
Talking with my back to him as I walked out of his room,I said, “Let’s take it week by week.”
Week by week—clean sheets, regular meals, and methadone were a given. To be taken or left. The methadone was never left. Each offering a saucer of milk for a feral cat. This cat began to tame, to leave his room, to follow the usual day/night cycle and very slowly to talk. Old habits die hard, he continued to wear every item of clothing he owned, to keep all possessions with him at all times and to eye anyone within three feet of him with suspicion. He even wore his wool hat, several long-sleeved t-shirts and a flannel shirt to bed.
According to the rules, I only needed to see him at 30- then 60-day intervals, but I felt duty bound to see him. Remembering my constant admonition to students—“Do not abandon your dying patients. Sometimes your presence is all that is required.” I resisted the urge to ignore him and forced myself to stop in for a weekly visit.
He began by showing me rashes—safest to start at the surface layer where there was a lot to see. He moved on to deeper layers, his abdomen for example, where it turned out that the pain was from gallstones. He continued to peel back more layers, to show me more. My armor began to loosen with successive visits and I noticed the return of some empathy and compassion week by week. So, the day that I walked in to the following scene, I felt sucker-punched.
I heard the yelling before seeing anything. As I rounded the corner I saw the head nurse waving a plastic bag over her head as she marched furiously down the hall. She was yelling at Michael who was following her with an all too familiar “Who me?” look on his face.
“I don’t even want to hear it Michael—save it for someone who does.”
“But I swear, I don’t know how it got there.”
“Michael, syringes and spoons don’t just appear miraculously in bedside tables. Don’t give me any more bullshit or else, cancer or not, your sorry ass will be back on the street.”
“Aw man, you know I wouldn’t do that ...”
I had to turn away and go to another nursing station; I’d seen enough of this scene.
For many weeks after walking in on the results of his impromptu room search, I reminded myself of the story of the frog and the scorpion before entering his room. My visits had become perfunctory again and all business. In the story, a scorpion pleads with a frog, to carry him to safety across a flooding river promising not to sting the frog. Eventually the frog has sympathy for the plight of the scorpion and carries him across. When they arrive on shore the scorpion fatally stings the frog. In response to “How could you?” from the frog, the scorpion answers “You knew what I was when you picked me up.”
I’d always hated that story, it made me lose hope for the human capacity to change and grow. I told it to myself before each visit to Michael convincing myself that it was futile to get involved in anything more than his bare bones medical care.
Eventually, as he got sicker and time went on, I forgot the story and compassion won out. I began to spend more time at each visit. He began to show me more. I began to say less. He began to cry. I stayed. He berated himself for past choices. I stayed. He railed at the unfairness. I stayed. Later, he sometimes slept and I stayed.
During the quiet times I began to wonder whether my own history of unclear, unhealthy relationships in my personal life was repeating itself in my professional life. I questioned the lure wondering how I could let myself be drawn in to the dance of caring for and about an addicted man. What was the purpose, where was the sanity, and was this a strength as a doctor or a weakness as a human being? Delusion, compassion, codependence? Who is helping whom here?
Now looking back, I see some differences. The old me didn’t know the word codependence , much less the concept of boundaries. Then, the relationships were deeply personal, now, with Michael, professional. Then, I felt that it was within my power to control whether things went right or not; now I know otherwise.
I now know that no matter how much you care, or love, or wish to make someone do or be anything they aren’t—it’s useless. Whether they are your children, parents, friends, spouses, or patients- they will not be anything other than what they are. No matter how you hope, bend, beg, plead, or blackmail—they will do what they can and will. It isn’t because you didn’t try hard enough, or didn’t love them enough, or didn’t do the right thing.
Maybe the best hope of doing any good actually ends up boiling down to the serenity prayer: knowing the difference between what you can and can’t control. Knowing what you can't control becomes clearer with time and experience. The courage to look at what you can control doesn’t always arrive.
It’s seductively tempting to try to fix someone else who needs fixing. Certainly more tempting than facing a fearless self-assessment. In the end, the self assessment invariably turns up “personal growth opportunities. My current growth opportunity was Michael. Could I navigate this physician/patient (or was it human/human?) relationship somewhere in between the poles of codependence and indifference?
I remember sitting in his room charting as he slept. Was I sitting there for his sake or mine? When he woke up, sometimes a he’d smile and go back to sleep, sometimes he needed to cry and rail against life.
“I can’t believe that I will never see the Grand Canyon, never go to Europe, never be with a beautiful woman again. I must have shot a million bucks into my veins, what a fucking idiot.”
“Have you ever tried convincing anyone with a needle in his arm that a different choice exists?”
”I just want the opportunity to see the real me, the true me …”
A more breathtaking view perhaps than any canyon.
The less I said and the more I stayed, the better. The best I could do was no harm. Odd to think that one of my finer moments as a healer came from resisting the urge to do or say much. Odd also to think how much healing had occurred in order for me not to try to do anything more than to witness and listen to him grapple with his past and future.
As he outlived his prognosis, warm weather came and in his short-sleeved t-shirt (he had stopped wearing all layers at once) I saw a tattoo that I had missed on original inspection. This was a pro job, in the crook of his elbow, a beautifully drawn and colored peacock. As I admired it, he told me that peacocks are revered because they eat poisonous stuff and create from it the beauty of their extravagant tail feathers.
Eventually, he died peacefully, in a warm bed, without hunger or pain. Despite a total lack of “real” family and old friends, I think he knew that he would not be forgotten. I still feel conflicted about my role as a healer and human being with some addicted patients and am grappling with believing that this conflict is inevitable. What isn’t inevitable is how I continue to make sense of it.