The last chapter

Taureef Mohammed

“WE KNOW you are in the last chapter. What we don’t know is how long that chapter is,” the palliative care doctor said to the elderly man who had been doing “just fine” until a few weeks ago when he was admitted to hospital with shortness of breath.

The doctor was kneeling on his right knee at the side of the bed. The elderly man was lying almost flat; the head of the bed was at a slight incline. His head was tilted to the right, towards the doctor. Their eyes were at the same level. Before kneeling to the ground, the doctor had unlocked and dropped the side rail of the bed. The doctor’s right hand was on the patient’s right forearm. They were connected.

I was sitting on a chair on the opposite side of the bed, looking on, clipboard in hand, making notes. There are some doctors whose voices are therapeutic and this doctor was one of them. He spoke softly. He did not shout. He did not assume the old man – who was wearing a hearing aid in his left ear – was hard of hearing. He did not talk fast. The pace of his words was just right. Although he was busy, he did not talk as though he was. His tone was empathetic. So that when he said, “We know you are in the last chapter. What we don’t know is how long that chapter is.” The message was received. There was no need to repeat. There was no need to rephrase. The elderly man knew what the doctor meant.

His words struck me like lyrics from a song: simple, clear and profound. And, like the lyrics from a song, it remained in my mind for the rest of the day.

“We know you are in the last chapter. What we don’t know is how long that chapter is.”

What was the last chapter about? What was so complicated about the last chapter that a specialist was needed to tell a person that he was in the last chapter?

The last chapter was a consequence of modern medicine. According to Lewis Thomas, American physician and writer, the “revolution” started in the 1930s. One word: antibiotics. “I remember the astonishment when the first cases of pneumococcal and streptococcal septicaemia were treated in Boston in 1937. The phenomenon was almost beyond belief. Here were moribund patients, who would surely have died without treatment…feeling entirely well within the next day or so.”

Death was aborted.

That was just the beginning. He continued: “…we became convinced, overnight, that nothing lay beyond reach for the future. Medicine was off and running.”

Lewis Thomas would go on to lead the Memorial Sloan Kettering Cancer Center in New York through the 1970s and early 1980s. “I look for the end of cancer before this century is over,” he wrote.

We are not there – yet. But a lot has happened. A lot. Medicine is no longer running. Medicine has taken off: it is flying. We now have available many different treatments and interventions for diseases of all kinds. And in the ICU, we can prop up life when there is none.

My patient had advanced heart failure, and he was being treated. But more importantly, with this hospitalisation, he had entered the last chapter, and someone needed to tell him. Why was this task so difficult for many of us?

We were experts in the penultimate chapter: the COPD chapter, the heart failure chapter, the cirrhosis chapter, the dementia chapter, the kidney disease chapter, the ICU chapter. We knew the penultimate chapter inside out. We could recite it, from memory, word for word with our eyes closed. We liked it there. The plot was simple: assess symptoms, examine, interpret test results, diagnose, treat. And the healthcare system, advanced as it was, operated largely according to this simple plot.

The last chapter, on the other hand, was messy, the conversations were grey, and the plot could be complicated. The language – the language needed to navigate ambiguity – was different. Getting everybody – doctor, patient, patient’s family – on the same page, the first page of the last chapter, required effort and skill, the same way threading a plastic tube through the radial artery up to the coronary artery required skill. And the skill like all other skills needed to be honed, needed to be perfected. The palliative care doctor kneeling at the bedside had perfected it.

Taureef Mohammed is a geriatric medicine fellow at Western University, Canada. E-mail: taureef_im@hotmail.com