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The Art of Medicine

In lieu of flowers

Katers, Laura A. PA-C

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JAAPA 36(1):p 50, January 2023. | DOI: 10.1097/01.JAA.0000902908.66162.9d
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The primary team consulted me about “The Curmudgeon,” a man with a long last name difficult to pronounce. I was told he was difficult to work with. I slipped and called him that once before meeting him. “I'm going to see the Curmudgeon now,” I'd said, before correcting myself—“I mean, Mr. C.” I reminded myself that difficult patients often require the most empathy.

One of my roles working in addiction medicine is assessing patients with substance use disorders for possible liver or cardiac transplantation. Mr. C. was admitted to the hospital with liver failure and newly diagnosed alcohol-related cirrhosis. He refused to talk to anyone about his alcohol use. I entered his room and approached the bedside gingerly, maintaining a welcoming smile behind my mask that I hoped he could read in my eyes. As soon as he saw me, however, he asked me to stop smiling and sit down.

“What are your credentials?” Mr. C. barked.

I wasn't put off by his sternness; in fact, my own curiosity grew. I earnestly explained my interest in addiction and mental health and why I do what I do. I was somewhat surprised when Mr. C. cut me off after several minutes, appearing satisfied. He sighed deeply, and then said, “Call me Leo.”

Leo hadn't been feeling well for some time. First it was slow weight gain without an appreciable dietary change, then frequent nausea followed by abdominal bloating and diminished memory. He'd established care with a primary care provider for these concerns. He completed depression and anxiety screens and checked boxes for his appropriate social and medical history. On the form where it asked if he drank alcohol, he checked: “Yes.” At the initial visit, the clinician lectured Leo not only on his alcohol use but also on the “weakness a human must have to drink at all.” The visit note, later read by Leo and his wife, barely addressed his medical concerns; but the term alcohol abuse was highlighted several times. He continued to feel poorly. Drinking helped. Years went by.

Leo knew he'd be dead had his wife not called 911, but he didn't want to be in the hospital because he felt stigmatized for his alcohol use. He was from a good home where alcohol wasn't the norm, and he only started drinking socially in college. For much of his adult life, his identity was tied to a professional career in the entertainment industry, where having a drink to unwind after work was common practice among colleagues. After Leo retired, however, his nightly glass of wine became a bottle before dinner. He struggled with his identity outside of work; he never did well with idle time. He read articles about alcoholism and exposés on treatment groups such as Alcoholics Anonymous; he formed opinions.

Leo was discharged the next day, preferring to be home to get his affairs in order. A new liver was off the table because he valued privacy over being under the microscope of transplant protocols and timelines.

One week later, Leo was readmitted to the ICU with altered mentation. In a rare moment of lucidity, he asked to see me. He was receiving a blood transfusion when I arrived. Although he wasn't a quiet or a patient man, we sat in silence for 20 minutes until the nurse departed. He wanted me to know that he never thought a few drinks a day would lead to this. He felt alienated by the double standard of substance use, where the folks who had the strongest opinions were often those who used themselves. He questioned how his own drinking had escalated. It was apparent to me that he'd never had these heartfelt conversations before, and I wondered how things might have played out if Leo's “Yes” to the question about his drinking years earlier had been met with curiosity and compassion instead of shame. As I listened, I realized the difficulty of ending our conversation, because I knew it was really a goodbye.

At last, I asked Leo if there was anything else he wanted to share so we could create space for it, and he answered quietly: “No. In these last few moments with you, I'm better. I feel ... better.” Gently, I laid my hands on his—those hands now swollen as his entire body struggled to breathe under the weight of anasarca—and I told him, “I will remember you, and I will be present for others so that they can share their stories too.”

He looked at me one more time, then turned away; I felt that was my cue to leave. Leo died in the hospital 5 days later, without the privacy or dignity he desired. But I like to think that in our conversations he finally received what he needed most.

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