232 April 1995 Family Medicine

Cornrnentary ____________________________________________

A Family Practice Death

Scoff H. Frank, MD, MS

It is an irony of my career that I
have been called on more often to
save a patient's death than to save
a patient's life.
Following a talk: I gave on al­
coholism, a member of the audi­
ence approached me hesitantly. "I
have this uncle," he started. Ev­
eryone has ''this uncle," I thought,
the uncle or aunt or father or sister
who no one wants to talk: about.
He went onto explain that Uncle
Jack was in the hospital for coro­
nary artery bypass surgery and had
serious postoperative complica­
tions. He suspected those compli­
cations were due to alcohol with­
drawal and asked if I would be
willing to see Jack as a patient.
When I told him yes, he looked a
bit guilty and said,. ''I warn you, . mind, his wife, Kathy, was a pro­
he's not a very nice man."
Three months later, when Jack
entered my office, the room
smelled of tobacco and alcohol.
He appeared disconsolate, un­
shaven, and gray in complexion
and mood. I took a brief history.
In addition to his bypass surgery,
Jack had cirrhosis (with marked
hypoproteinemia), hypertension,
severe emphysema, and disabling
chronic idiopathic lymphedema in
his lower extremities. It was clear
that he didn't want to be in my
office. He was there on a promise,
probably to his nephew, or perhaps
to get his wife off his back. This
bitter, rude man was the epitome
ofthe "hateful patient," the "heart­
sink" patient, labeled so because
your heart sinks when you see his
From the DepartrnentofFamily Medicine, Case involvement with that organiza­
Western Reserve University, Cleveland, Ohio, tion. He refused psychiatric refer­
name on your schedule. I con­
fronted him tentatively about the
alcohol on his breath. He admit­
ted with provocative pride that he
was an alcoholic and issued the
clear, unstated challenge, 'What
are you going to do about it, doc­
tor." I didn't expect to see him
back. In fact, he was so intoxicated
I didn't expect him to remember
anything about the visit.
. But, he did come back. In fact,
he came back again and again. We
started chipping away at his medi­
cal problems. Foremost among
these were his alcoholism, his de­
pression, and his nicotine depen­
dence. Jack considered himself a
failed man. He lost his job because
ofhis alcohol use. Worse yet in his
fessional success, working her
way up in her workplace as Jack
worked the opposite way in his. He
had been disowned by his family.
He no longer slept in the same
room with Kathy, and he didn't
speak to his seven children.· Jack
was no longer a family member
but a boarder in his own home.
Jack was without- without faith,
without self-worth, without Jove,
without support, without health,
and without hope.
I consistently tried to give Jack
a message of hope, that his return
to health was possible through ab­
stinence, that recovery was worth­
while, and that he was uniquely
worth recovering. But he had been
through inpatient alcoholism treat­
ment before and refused to try
again. He had been to Alcoholics
Anonymous and rejected any new
ra1 and refused family counseling.
The only help he would accept was
the help and support offered in our
office. I informed him he could
quit on his own and that, in fact, I
was confident he could do so ifhe
was totally committed to his own
recovery. But I also told him he
was choosing the most difficult
pathway possible to sobriety and
health. I suggested that his odds
ofrecovery were perhaps 5 in 100
without help and 60 in 100 with
formal treatment. He was resolute
but agreed to consider formal sup­
port if he didn't make progress. I
reassured him that my help was
available to him whichever path­
way he chose.
Gradually, Jack got better. He
demonstrated longer and longer
periods of abstinence and his re­
lapses became shorter and less se­
vere. As his abstinence became
more stable, his mood lifted a bit,
but not much. I started him on
treatment for depression and he
responded welL Althopgh he was
a former executive, he took a job
pumping gas and then a job as a
part-time tax preparer. His per­
sonal meaning was intimately tied
to his work ethic and productiv­
ity. He began to smile during his
visits. I began looking forward to
seeing him. Jack had formerly
been caught in a negative self-re­
inforcing cycle, in which bad led
to worse, worse to intolerable, and
intolerable to loss of control-a
"black hole" drawing him deeper
into despair. Now, for the first time
in many years, he began to expe­
rience a positive self-reinforcing
cycle in which good things led to
better things, including a restored
 .Commentary Vol. 27, No.4 233

sense ofpersonal control. After 18 X ray. Bronchoscopy revealed a: ing shallowly and was notrespon­
months of abstinence and re­ squamous cell carcinoma, and sive. When I arrived at their home
lapse, Jack found stable sobriety. the oncologist indicated that the entire family was there. Jack
He returned to his church and Jack's expected survival was had died, the family thought, about
later to his faith. His idiopathic measured in months. 5 minutes before I arrived. I laid
lymphedema disappeared. Three When I got the news, I spoke my stethoscope on his chest and
years after he first walked into with Jack and suggested that he left it there longer than necessary
my office, Kathy accompanied bring his family in to talk things in ceremonial confirmation of
him to a visit The look of silent over. I will never forget our coun­ the quieted heart. The family's
pride on their faces remains one seling room overfilled with his grief was peaceful with gentle
of the most vivid memories of my family. overflowing with shared tears and embraces. Goodbyes
career. matching for me the joy I concern, grief, and love. We spoke had been said. lack died the way
experience.in attending the birth . openly and frankly, .without se-. he . wanted-no pain, alert
of a healthy child. Jack had rec­ . crets. He was not a candidate for throughout, and quickly when
onciled with his wife and with his resection, and after careful discus­ the'end came.
children. He was now with-with sion, he declined chemotherapy_ My wife and I attended lack's
faith, with self-worth, with love, We talked about his wishes regard­ funeral. We were both moved to
with support, with hope, and with ing resuscitation (none) and abo.ut tears by his children's readings and
improved health. the manner in which he wanted to remembrances. I feel humbly
Though lack had made tremen­ live his last days. He expressed a aware ofthe effect of my relation-.
dous strides in his recovery, he did strong desire to stay out ofthe hos­ ship with Jack. I didn't exactly
not initially respond to efforts at pital until death was imminent and save Jack's life, but I guess you
smoking cessation. His emphy­ then to enter the hospital to spare . could say I saved his death. The
sema worsened with collapse of his. family. the burden of having consequences of lack's recovery
the lower lobe of his right lung. him die at home. Every member from alcoholism will, I believe,
We suspected that cancer was of the family objected, insisting reach through generations. The
present, but despite aggressive in­ that he would die at home, with lives of his children will be very
vestigation, none was found. He them, where he belonged. I agreed different than if he had died a
was followed with serial chest X to facilitate hospice involvement mean, bitter drunk. Their relation­
rays, cr scans, and bronchoscopy. and provide home visits. I assured ships with their own children will·
About 6 years after I began caring them I would do everything I could be altered because of their recon­
for him, lack finally responded to to be there when lack died. They ciliation with their father. lack
nicotine replacement therapy and expressed relief that they wouldn't· died with honor, and when people
quit smoking. But, within a few be alone. . remember him, their memories
months, he began to lose weight I Jack accepted radiation for pal­ will be filled with pride.
knew he had a cancer. He knew liation and did remarkably well. I In medical school, we were
he had a cancer. We just couldn't visited their home weekly, occa­ taught to always ensure that our
find it We looked in his chest and sionally more, sometimes less. He patients die a "Harvard death"­
. his bowel and his throat and his never had pain. His biggest prob­ with all oftheir eleetrolytes in bal­
brain and his belly and when we lem was sleep, which was rem­ ance. Since then, i have learned
found nothing, we tried to feelre­ edied with aggressive sedative to help patients die a "family prac­
assured. Kathy accompanied him medication. Less than a week af­ tice death"-with all of their psy­
now to nearly every visit. Two ter a home visit and 6 months af­ chosocial issues in balance.
months later, the cancer declared ter diagnosis, I received a call from I find solace in knowing
itself, ironically on a routine chest the family that Jack was breath- Jack did.