BMJ  2003;327:E176 (4 October), doi:10.1136/bmjusa.02120005 (published 20 March 2003)

BMJ USA: Filler

The man who was afraid to die

From BMJ USA 2002;Dec:677

When I started to practice medicine in 1950, I was terrified. I had never owed a dime in my life, and suddenly I found myself in debt for a house, a new Chevrolet sedan, an examining table, and some odds and ends of medical equipment. Furthermore, my wife was pregnant.

How ridiculous it seems today to look back at that time long ago and recall that I was uncomfortable about being young. Every now and again when I was making a house call on a new family, the man who opened the door would look a bit surprised and say, "Doctor, we were expecting an older man." I used to pat him on the shoulder and assure him I was growing a bit older every day.

One of the first people I met was a florid-faced, likable fellow some years my senior by the name of "Swede," the only name by which I can remember him today. Actually, I met his wife first when she became my patient. Swede's wife was one of those women who had weighed life and found it wanting. I suspect she suffered from mild depression, and she certainly suffered from a lot of anxiety.

Swede's wife never succeeded in telling me exactly what was wrong. She would burst into tears every time she came into my office. Then, when I asked her what was wrong, she would protest tearfully that she really didn't know but she just didn't feel good. I used to listen quietly for fifteen minutes or so, nod my head from time to time, and then tell her I wanted to see her again in about two weeks.

One evening I was surprised to hear the doorbell ring, and when I opened it, Swede was standing there, hat in hand. "Doc," he said with a broad smile, "I was up on the Tarryall the other day, and I caught some nice brook trout. I thought you and the missus might like to have a couple." With that he handed me a package, and I thanked him and asked him in. "Oh, I can't stay," Swede said, "I've got to get on home. I hope you'll enjoy the trout. Oh, by the way, Doc, my wife says you're the best doctor she's ever had."

I was flooded by a strange mixture of emotions. I was deeply touched by Swede's gift, and I was surprised that his wife was pleased with my care. It seemed to me that I had done nothing for her. I don't think that I ever wrote her a prescription.

When hunting season rolled around, Swede appeared on the porch again. This time he brought us some venison from a young buck he had shot. Again I was sincerely moved by his gesture of friendship, but I was even more pleased when he went on to say that he was grateful for all I had done for his wife.

Not long thereafter Swede showed up in my office. "I'm the patient this time, Doc," he began. "I don't know. For some time now I've been coughing a lot more. I know I ought to quit smoking, and I will one of these days. Somehow, my chest doesn't feel quite right."

I found nothing unusual when I examined him, but an x-ray of Swede's chest showed a large, ominous shadow in his left lung. I referred him to a thoracic surgeon, and I later assisted at the exploratory thoracotomy. Swede had an inoperable cancer of the lung. When we were closing Swede's chest, the surgeon said to me, "You know this man better than I do. I think you should be the one to tell him he has cancer."

I remember so vividly standing outside of Swede's room in the hospital and dreading the prospect of facing him. But somehow, I forced myself to open the door and walk into his room.

I took his hand, swallowed hard, and looked Swede in the eye. "Swede," I said, "you have a tumor of the lung, a bad one." I somehow couldn't bring myself to use the word "cancer," which was so dreaded then and continues to strike terror in the hearts of newly diagnosed patients today. "We weren't able to remove it. It was wrapped all around the aorta, the big blood vessel coming off of the heart, so we're going to send you for x-ray therapy." I didn't add that x-ray treatments would not cure him, that at best they would add a few months to his life.

Swede was treated for some weeks by a therapeutic radiologist and then, not surprisingly perhaps, I lost track of him. About ten o'clock one evening Swede's wife called me in tears. "Doctor Mac," she pleaded, "would you come out and see Swede? He's in terrible pain."

I hauled myself out of bed, dressed, and drove several miles to Swede's modest home. When his wife opened the door, she said, "Doctor Mac, the pot's on." I walked into the bedroom and shook hands with Swede. He said, "Doc, I can't stand this pain any more. I just can't take it." "Swede," I answered, "Don't worry. I'll give you a shot of morphine, and in a matter of minutes you'll be sleeping like a baby." "Hell, Doc," Swede replied, "there's a registered nurse living next door, and she gave me a quarter of a grain of morphine just a half an hour ago."

It struck me as very strange that Swede's pain had not been relieved by the morphine, and I found myself taking a closer look at him. Somehow, he didn't have the look on his face of a man in severe pain, but he did look extremely anxious. I suddenly got an idea. "Look, Swede," I said heartily, "I get out in this neighborhood pretty regularly, and I'll tell you what. Every time I'm out this way I'll just stop in and have a cup of coffee with you, and we'll chat a bit."

It seemed to me that patients with cancer all too often found themselves feeling alone and abandoned. Friends and relatives were afraid they would be uncomfortable with the patients, and so they avoided visiting their dying friends and loved ones.

"Gee, Doc, that would be great," Swede said with a smile. Then he added, "God, Doc, I suppose the only thing I can look forward to is having more and more pain." "Swede," I answered honestly, "I don't think so. I suspect you will lose strength over the next few months, and you'll lose some weight. Then, one day you'll just fall asleep and never wake up."

I found myself praying to whatever gods there be that Swede wouldn't develop any metastases, especially to his bones. That could be extremely painful, but it seemed unlikely since he had gone so long without developing such complications. "Why, hell, Doc," Swede said cheerfully, "I can take this. This pain isn't all that bad."

I gave Swede a prescription for empirin and codeine, and he never had another injection of morphine. I kept my word. I stopped by to have a cup of coffee whenever I was in his neighborhood, and Swede and I chatted about everything under the sun, particularly about experiences we had on hunting and fishing trips. Swede continued to lose weight, and he spent more and more hours asleep during the daytime and nighttime hours. One morning Swede failed to awaken. It was painful for me to call on him for the last time and tell his wife that Swede was no more. I will remember that lovely man as long as I continue to breathe.

Washington, DC DOCTOR1MAC{at}aol.com

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