My Father's Final Lesson

When I was 16 years old, my dad had a heart attack. I still recall studying in my room when my mom came in to tell me he wasn’t feeling well. At the time, I was a volunteer in the emergency department at our local hospital, located in the tiny Pacific Island of Guam. I recall asking him what he was experiencing: elephant sitting on his chest (yes), shortness of breath (yes), pain down his arm (yes)—it was my first diagnosis, and unfortunately, I had diagnosed an acute myocardial infarction in my own father. As I sped toward the hospital, my dad lost consciousness. I watched helplessly as they wheeled him into the code room. I watched the door close amid a flurry of controlled chaos. During those tense hours in the hallway, time stopped for me and my mom. The only thought I had was “But….” As he was fighting for his life that night, I thought about all the things we had not said and done. I feared that I would lose him before I graduated from high school. Fortunately, he survived that night and recovered without sequelae. Over the course of decades, his heart disease became a chronic problem, devolving into a cardiomyopathy. Still, he lived well, traveled frequently, and golfed 18 holes with regularity. That is, until 2 years ago. I was called home then—to Guam. He lay in an intensive care unit on a morphine drip. The doctors knew there were no treatment options left, and they had feared he would not survive this event. My father had not heard them; he had asked for me. Armed with my medical degree, I stepped into the role of patient advocate. Knowing my dad’s disease was terminal, I was his “son the doctor” and worked with his medical team and my family to figure out what to do next. I realized that my family, and in particular my dad, had looked to me for guidance. In that situation, I had a flashback to my days as a resident at Yale-New Haven Hospital. I still remember being an intern, having to talk with an inpatient about his prognosis. I remember the feeling of discomfort, of feeling unprepared. Apparently, this was not unique to me; studies have shown that as residents, less than half of us are comfortable with, let alone knowledgeable about, delivering bad news [1]. Yet with wonderful mentors, an oncology fellowship at Memorial Sloan Kettering Cancer Center, and years spent as an oncologist, I had found my own way of handling this task. I had learned that patients want information yet do not want to lose hope, so I learned to engage them both cognitively and affectively, to discuss their own situation and prognosis using words and phrases tailored to them, while aiming to be attuned and responsive to emotional cues that arise. This skill set became an important tool for me at this particular moment in time, as I helped my dad face the end of his life. Before I left Guam, I saw him discharged to his home and set up with hospice care. We spent time together, discussing the things that had made him happy and that he would miss. I got the chance to tell him how much I loved him. He told me he was proud of me and the family I had created with my partner. Four weeks later, my phone rang while I was driving home from work. “Don, there’s something wrong with your dad,” my mom said. “What’s wrong?” I asked, aware that my heart had started to thump faster and harder. “He’s not moving or waking up,” she said. “Can someone feel his chest? See if you can detect his heartbeat. If not, feel his neck for his pulse.” After some shuffling, my sister retrieved the phone. “There’s no pulse.” “Can someone grab a mirror and place it under his nose? Check to see if he’s breathing.” A pause followed, and then “No, I don’t think he’s breathing.” “Get a flashlight—check to see if his pupils contract.” A longer pause as my family tried to locate a flashlight, and then, “No, there’s no reaction.” “Let me speak to Mom, then.” “Hello,” my mom said. “Mom, Dad’s gone. He’s dead.” And just like that, I had pronounced my own father’s death over the telephone. These thoughts came to me after seeing the movie, Extremely Loud & Incredibly Close. It’s a movie set after 9/11 and tells the stories of death—one violent and immediate, and the other protracted as a result of illness. It was, in a way, my own experience with my dad. In the one, I was young and shocked to learn I could lose my dad so suddenly, with so much left unsaid. In the other, I had become a man in the presence of my father, developed a friendship as equals, ultimately bore witness as my dad lived out the last weeks of his life, and, most important, experienced closure before he passed on. In the end, I believe my dad experienced what I think people (and my patients) deserve when that time arrives—a “good death.” If there is anything that oncology (and medicine) makes us realize, it is the gift of time. Although cancer cuts life short for the majority, it usually will provide for time at the end of life. As physicians, we should not rob our patients of the time at the end of life, the opportunity for closure, and the chance to say what needs to be said. It is an opportunity not afforded to many others, and it was probably one of the most important lessons my dad taught me.