Death and dying had been my trade for the last four years, but that morning, I didn’t want to deal with it. One of my long-term patients, a man in his mid-90s, had become suddenly and seriously ill a few days earlier. His family knew he didn’t want aggressive treatment, and so they had moved him to an inpatient hospice in a nearby beach town.
The next day I happened to be in the area, where I had just finished a house call. I sat in my car and considered a quick detour to the hospice, only a few miles away. But I couldn’t make up my mind. I turned on the radio and listened to the news headlines, anything to delay my decision.
I’m a primary care doctor with a somewhat unusual job. I spend my days driving to visit my frail, elderly patients in their homes. A lot of my job entails doing things I never did in my years of practicing office-based medicine: cutting toenails, changing light bulbs, peering into refrigerators, poking through drawers and shelves for missing keys and reading glasses, listening to stories about old photographs and mementos. I stop things more than I start them: like medications, because side effects loom large; and screening tests like colonoscopies, which are designed for people with longer life expectancy. My boss likes to joke that we house-call doctors don’t do anything; we just sit there.
That’s what I was doing then, in my car, just sitting there. But it wasn’t the good kind of sitting there. I pressed my fingertips into the hard rubber of the steering wheel. I berated myself for being a wimp, at the same time reasoning that if my patients had to leave home for a rehab facility or a nursing home, they’d have doctors there taking care of them. I could always call, and I often did. If I happened to be nearby, I might even pay a friendly visit. But I didn’t have to. Most doctors didn’t travel to those sorts of places to see their patients. And yet I couldn’t think of any reason not to visit this old man for what probably would be the last time.
It wasn’t the thought of the patient’s death that held me back. A big part of my job is helping families come to terms with a loved one’s imminent demise. These conversations are some of the most meaningful parts of my work. I like setting up home hospice services for my end-stage patients because I know how the wise guidance and gentle touch of the nurses and aides can soothe and give solace.
What I was avoiding was the inpatient hospice building itself: the shared physical space and sheer number of people dying in it at once. Inpatient hospice is for the truly terminally ill, those just a stone’s throw from rigor mortis. The hospice doctors won’t admit patients unless they have no more than a few days, or at most a few weeks. I wasn’t used to this dismal calculation. In outpatient medicine, one or two of my patients might be dying at the same time; in a hospital setting, maybe a handful would be scattered among the merely sick. Even the hospice wing in the hospital was just a small portion of the place, not the whole godforsaken building. The inpatient hospice, on the other hand, was a house of death — or, more accurately, a former office building of death, albeit with a lovely view of the shore.
The truth was that in all of my years of practicing medicine, I had never been inside an inpatient hospice. Several years ago, my husband, also a doctor, filled in at the hospice for a weekend. What struck him was how many young people were dying of all kinds of horrible cancers, and the creepy term their caregivers used: transitioning. Transitioning referred to the time when the end grew nigh, with familiar signs like the death rattle — a telltale fluttering of secretions in the throat — and the more subtle harbingers of death that only hospice people seem to know about: the crease in the earlobes, the mottling of the skin on the feet. I pictured a large ward holding endless beds of transitioning or near-transitioning patients, a perpetual drone of sobs from the waiting room, every hour another body wheeled away, a steady line of hearses idling in the parking lot like taxis at a train station. I didn’t want to see my old patient in that ward of misery. I didn’t want to see him suffering. He was probably so near the end that he wouldn’t know me anyway. And what if I found him surrounded by a dozen or so tear-streaked relatives, all expecting me to spew forth some end-of-life profundities?
I backed out of the driveway and headed slowly toward the highway. I would go to his funeral, and that would be enough. And then I sighed and turned into the next parking lot. I wasn’t fooling myself. This was a cop-out. It didn’t mesh with the image of the good doctor I imagined myself to be. I was lucky to have this opportunity, I told myself — most doctors, confined to an office or a hospital, couldn’t do this — and I knew I would regret it if I didn’t go.
In the hospice parking lot, no hearses in sight, I sat for a moment and took a couple of deep breaths. I buttoned my coat and hurried down the long path to the front door. Inside, it was quiet, and cozy, and homey. Somebody was playing a piano. Bright handmade blankets were draped over the couches. The man at the front desk wore a wool sweater and smiled up from his book when I asked him where I should go. Instead of the grim ward of suffering that I had imagined, a hallway led to semiprivate bedrooms.
My patient lay in bed in one of them. The other bed was empty. The old man grabbed my hand with such firm recognition and affection that it was hard to believe he was sick. And harder to believe that I had hesitated, that I had almost cut and run. But mostly, I felt regret, regret that I had let my reprehensible fear of the hospice building foil final hugs or handshakes with other patients who’d lived for a while in this radiant place.
There were some family photos on his windowsill, and the sun glinted off the water so brightly I had to look away.
Anna Reisman is a general internist and an associate professor of medicine at Yale School of Medicine. She has written for Slate, Discover and the Los Angeles Times.