On a cold, dull Sunday in January I began studying charts, getting to get to know my patients before making rounds as part of my geriatrics fellowship in inpatient internal medicine.
Joseph Teal was an 82-year-old man diagnosed with end stage laryngeal cancer three months earlier. At that time, his voice was getting hoarse and by the time the diagnosis was made there was already a mass large enough to block some of his airway. Mr. Teal was in the hospital for chemo and radiation therapy.
In addition to the cancer therapy, he had needed a tracheostomy (a tube which came out of his neck and went to his lungs). Because the mass in his throat obstructed his esophagus, he was no longer able to eat, so he needed a tube that went directly into his stomach in order to supply him food. When he tried to eat, food would either get stuck in his throat or go down into his lungs, risking an infection. He was already on antibiotics for just such an infection he had acquired a few weeks before.
I gathered my information and walked into his room. He sat with the head of the bed elevated, so he could watch television. Mr. Teal’s body was cachectic—or, weak—and he looked tired. The definitions of each muscle showed in his neck. He seemed enveloped by his hospital bed, like a lone tree on the prairie.
His wife, Trudy, was sitting in the chair next to him. She was a slightly overweight, elderly lady with short grey hair, and large oval glasses that took up much of her face. I knocked on the open door as I entered the room and introduced myself.
“Hello, I’m Dr. Mashaw,” I said. “I’m going to be taking over as your doctor tomorrow.”
Mr. Teal didn’t even look up. His eyes were glued to a football game on television. His wife, though, smiled.
“It’s nice to meet you,” she said. “Don’t mind Joe—he loves the Giants.”
When a commercial finally came on, Mr. Teal turned his thin head my way and joined in the conversation. I briefly described my understanding of his current issues and explained that I would make sure his medical needs were taken care of, apart from his cancer therapy. Then I asked him what his expectations were.
“My cancer doc explained everything,” he responded. “I’ll be out of here after the therapy, and I’ll be fine.”
That was curious, I thought. Did I read his chart wrong? My understanding was that the cancer therapy was palliative—intended to reduce pain, make the mass smaller in order for him to live slightly longer. Or to make it possible for him to eat again and maybe breathe without the tube. I made a mental note of his comment and finished our conversation. It wasn’t a long one; he had a game to watch.
Back at the nurse’s station, I double-checked Mr. Teal’s chart. His radiation oncologist had also noted earlier that day that the Mr. Teal’s therapy was palliative. At this point, after half of the treatments, there had been no diminution of the mass. The radiation oncologist quoted Mr. Teal in the note; the patient wanted to continue the therapy, to “make me live as long as possible”. This really didn’t sound like the conversation I had just had with him in the room.
The next week, I visited Mr. Teal daily. In the morning I would see if there were issues to fix or symptoms to alleviate. Then in the afternoon, I’d come by to see how he was doing and talk for a while. I learned that, although in his 80s, he had just retired six months ago—he had been a caretaker at a nearby country club. His wife was about the same age, and they had been married 62 years. He had two children, a son in Connecticut and a daughter in Pennsylvania.
Mr. Teal was originally from New Jersey, and that’s where his love of the Giants began; he used to watch games with his son. Our conversation turned to football, and I learned that Mr. Teal was frustrated with their star quarterback, Eli Manning, who was from a famous family of football players. Mr. Teal thought Eli Manning was an inconsistent quarterback, but he explained that he started to see potential during the last few games–the Giants were doing well enough to make the playoffs. This tired man, drained of life from the cancer and his therapy, was now full of energy. Whenever he talked about his Giants, his eyes lit up, and he smiled.
Still, his certainty about his cancer was alarming. Whenever I brought up the subject, he indicated no doubt that he would live another ten years. This didn’t seem healthy to me. He had been told in no uncertain terms by his oncologist that the therapy wasn’t working. He had months to live at most. But those words didn’t seem to register; he was in denial and that bothered me.
In medical school, I was taught a bit about the psychological process of dying. In the 1960s, a physician, Elizabeth Kubler-Ross, suggested that we progress through defined phases when coming to terms with being terminally ill. Those stages in order are: denial, anger, bargaining, depression, and acceptance. I envisioned these stages as a blueprint for the “correct” way to die. For many people it brings a sense of peace to reach the stage of acceptance. So as a physician, I thought it would be my duty to at least broach the subject. I felt my job as a healer was to help guide my patients at the end of their lives.
I was Mr. Teal, I would want to get past the hopeless and painful cancer therapy and go home. I would want to get my affairs in order. “Get past the denial!” I thought. So the next day I set about explaining to Mr. Teal his prognosis. Because of his tracheostomy tube, he could only talk after I placed a valve over his tube.
I started with some small talk about the Giants. They were looking better and better. After a while, I placed my hands on his. “You know, Mr. Teal,” I started hesitantly. “I spoke with your cancer doctors and it doesn’t seem like this therapy is helping. I don’t think your cancer will be cured.”
“Oh my God, doctor!” he responded as if having been slapped in the face. “This can’t be!” He paused for what seemed an eternity. “How long do you think I have?”
“This is a really difficult question to answer,” I said honestly. I began talking in circles, and his look of terror increased each moment I didn’t give him an answer. “The best I can guess is weeks to months.”
He looked at me in astonishment, the words turning in his mind, like a Chinese finger trap. He finally answered, “Why would God do this to me?” Then, a look of anguish on his face. “I’ve worked hard all these years, I had just retired…. This isn’t supposed to happen.”
I sat beside him, but his eyes were focused on some distant place, the disbelief and horror showing on his face.
Sure enough, the next stage, anger, reared its ugly head like a lion cornered by hunters. Why would God do this to him? Why would he be such a good person and finally retire after so many years of working only to have three months to live.
What fury had I unleashed? What new pain had I created? What was I doing harming this man when my job is to do no harm? Every moment I sat on his bedside talking, I wanted to get up and run away, denying that I had hurt this man so badly. But no, there we were, I, the one who had torn this man’s bandage off, and, he, the one who had to deal with this new gaping wound. He finally calmed down, and I left. Shame weighed on me for hurting him so much, even though I felt my intentions were good.
The next day, I went back to see how he was doing. Was he still angry? Or perhaps he had moved on to the stage of bargaining. Was he now making a deal with the same God he was so angry with a day ago?
“Mr. Teal,” I said, hesitantly. “How’s it going today?”
“Great! I can’t wait to get out of here and live another ten years”.
I did a double take. Was he mocking me? Was he kidding? No, he was back to denial, as if the previous day had never happened. Sometimes, your mind takes you to the place you need to be, and no matter who or what tries to alter it, it knows what is right.
As the days passed, it became clear that Mr. Teal’s chemo- and radiation therapy were not helping. The cancer in his throat continued to grow, and it was making him weaker and more susceptible to worsening infections. One day, I spoke to him about his wishes. I wanted to know what he wanted most at this point in his illness, without bringing up curing his cancer.
“I just want to eat some soup,” he said in a weak, wheezy voice. He had to talk through the valve that was placed on his tracheostomy tube. “I just want to go home and to eat some soup”.
The next day I set up a meeting with his family, the radiation oncologist and me. The gathering was awkward and difficult. His family realized he was not improving with his therapy and that the cancer treatment should be stopped. I relayed to his wife his wishes about eating—about the soup. She completely understood. Her husband had worked to support her and their children until he retired three months before the cancer diagnosis. They were supposed to watch the world go by together.
But instead, he lay in a bed with a tube in his neck to breathe, and a tube in his stomach to be fed. It was unsafe for him even to eat normally. How could this cancer be so cruel to take away from him even the simplest expressions of what it is to be human? I explained to her that if we could stop the cancer therapy, then maybe we could focus on making him comfortable with the time that he did have left. If we let him eat and he did aspirate the food then he would at least have been briefly happy. We could also focus on placing him somewhere less busy, somewhere he might be more comfortable, instead of in a hospital room, with nurses bustling in and out, regularly poking him with needles.
This plan made sense to his wife, and I noticed a moment of relief in her eyes. However, we knew he would not agree to this if anyone other than Trudy suggested it. She broke the difficult news as only a wife of six decades can do, and I watched intermittently as they spoke for hours, hands clasped, laughing and crying. In the end, he agreed to be placed in a hospice house.
But the day of the move, Mr. Teal was terrified. He became anxious, and nothing seemed to calm him. Maybe he realized that this meant that he would die. I visited him the following day. Families are encouraged to bring items from home to make hospice more comfortable. Mr. Teal’s room had a quilt on a couch and his bed was covered with a blue blanket Trudy had brought from their home. Facing his bed, underneath a large television, was an old picture of him with his right arm around his teenage son’s shoulder. They were in front of Giants stadium, before a game. Mr. Teal had a smile on his face and his pride glowed out of the picture.
“So, what do you think, Mr. Teal?” I asked as I entered his room.
“I’m very happy to be here.” He responded in his raspy voice. “I think you were right about this place. But I can’t wait to go home.”
There it was again. Any push from the outside world might disturb him enough to start to deal with death, but his mind would gently slide back into what was most comfortable for him. I didn’t pursue further.
“Have you been able to eat yet?” I asked.
He began to smile, “I had a couple spoons of chicken soup this morning. It was like a gift from God.”
“So are you excited about the Super Bowl?” I asked.
“Definitely,” he said with his smile. “There’s going to be a huge upset.”
I smiled. The Super Bowl was a week away, and we agreed that I would come by to watch it with him, and maybe we could enjoy some soup together.
Mr. Teal died two days before the Super Bowl. Trudy was with him, and he was comfortable before his last breath. During his last days, he became too weak to interact. Many think that this is the body’s way of withdrawing from the world in preparation for death.
Everyone dies alone. We can have ’round the clock nursing care. We can be surrounded by an army of doctors and nurses performing CPR on us when our hearts stop. But our death will be our own. Our brain’s ceasing to function, to think, to process, to carry our souls is completely our own to experience. Whatever happens, whether it is a cessation of reality, or a bright light with our loved ones waiting, will be ours to discover. And in just the same way, we all have the right to deal with it as we choose. Why had I forced Mr. Teal to deal with his death in a certain way? I had thought going through all of the stages is how we can make peace with our passing—a “good death.” And I felt it was my duty to help patients through that process, even if I had to force them. After meeting Mr. Teal, I realized my premise was flawed.
* * *
Two days after Mr. Teal died, with 35 seconds left in the Super Bowl, that same erratic quarterback he had complained about before, threw a touchdown that shocked everyone. He put the Giants ahead and they beat the so-called unbeatable New England Patriots. As it happened, all I could think about was Mr. Teal cheering, smiling and eating soup.
Arsheeya Mashaw grew up in a small town in Indiana. He went to college in California and then on to graduate school in New York where he met his wife. He taught at a public high school in North Carolina before attending medical school. He is a family doctor and geriatrician in a rural town in Virginia. His favorite part of medicine is observing human experiences, emotional journeys we all deal with during our lives. You can follow along with some of his more memorable chronicles at www.doctormash.com.
