The first time I gazed upon Mr M, an elderly man who had been in the hospital for several days, I was surprised by his gentle demeanor and warm eyes, after hearing the story of his suffering and abandonment that my colleague had shared. He was an 83-year-old man with a history of dementia and a stroke, which, years ago, had left him disabled, needing help with the activities of daily living: dressing, bathing, feeding himself. Yet he was able to walk with the aid of a brace that required special shoes.
He had been dropped him off in the emergency room several nights before I met him by an acquaintance who reported he had found Mr M in bed when he came to visit. He could not stand and had not eaten in days. His caretaker was nowhere to be found. The emergency room doctor had carefully examined him, reporting that he was weak and dehydrated. When she pulled the blanket back, she was disturbed by the discovery of several large, terrible ulcers. One was on his sacrum, an area that is often prone to the development of ulcers when patients are bed bound, and not moved frequently. The other was over the right hip. It was the size of a dinner plate and lay where the top of the hip projects. His stroke had affected his right side and it appeared he had been lying on it for some time. There wasmention of both the police and adult protective services becoming involved. For now, our focus was on our patient.
After reviewing his records of the last 12 months, I learned he had been both a jazz musician and a lab technologist at our hospital for 40 years. Though crippled by his dementia and stroke, he was well enough to visit his primary care physician and neurologist several times during the last year, always accompanied by his caretaker, who was described in complementary terms in their notes. They documented stable health and contentment; describing a kind person who loved going to his appointments because it gave him a chance to leave his house. His caretaker provided almost around-the-clock care, and had been doing a good job, not an easy task. Then, about two months ago, “he has a new caretaker,” was written in the last note. I could find nothing more until he was hospitalized.
When I met him for the first time, he greeted me with a big smile and asked how I was. I did remember his face, but not his name. I smiled back telling him, “That’s supposed to be my question, Mr. M!” I began asking some simple questions, “Was he in pain? How was his appetite?” He answered brief “No” and “Good!” responses, but he had spent a lifetime working here and was much more interested in how former coworkers were (who were beginning to visit) than he was in discussing his ailments.
The wound care nurse walked in at that moment, telling me it was time for his dressing changes. She, too, knew him, as did his PCT (patient care technician as they are inaptly named). Eduardo had come from the Philippines many years ago and had been here almost as long as Mr M. His job was to help patients bathe, walk, turn them in bed when they were too weak, bring them meals, feed them when they couldn’t feed themselves, and be a jack of all trades for the nurses. All of which he did it with grace. He had asked to be assigned to Mr M. I was touched by the loving way he and others handled and cared for him. There was a gentleness and a hovering that was palpable. Eduardo helped us get Mr M ready for the dressing removal. I saw the huge black leathery eschar, or scab, on his hip, and the smaller, yet suspicious, closed ulcer over his sacrum. An eschar is a protective covering the body makes for itself, that can allow the tissue beneath to heal, or in less desirable circumstances, to fester and rot. We were unsure of what lay beneath and decided to ‘etch’ the eschar. I took a fine blade and made little scoring marks in its very tough surface, not always breaking through. This would allow the salve to work its way in and un-roof it. Thankfully, it was a painless procedure.
I had no idea how much he understood his current condition or knew what had happened to lead him here. I had a faint sense that life may not be the same for him again, and asked him, as I do so often of my patients with chronic or even life-threatening illnesses, “What do you hope for Mr M? Wish for? What is most important to you now?” I did not understand the depth of his dementia at that moment, didn’t harbor the idea he might not understand what I was asking. “My shoes” he replied. “Getting my new shoes so I can walk again. My caretaker was supposed to get them for me, but she hasn’t.” He looked up at me. “I want to walk again.” I thanked him for sharing and told him we would work as hard as we could with that goal in mind. He thanked me as he always did, every time I saw him, even in the face of such difficulty.
I met both his social worker and a detective who had been assigned to his case in one of the small conference rooms. I gave a brief update on his condition. The social worker then shared what she had discovered so far. The new caretaker had disappeared, and a story of abandonment and neglect began to unfold: Stolen credit cards, loans in his name against the home he lived in and owned (paid for). How could that possibly happen, I wondered? I could picture him signing forms with a grateful smile, not knowing she was taking his life’s earnings from him. There was also concern that his testimony would be invalid because of his dementia. His family, a niece and nephew, lived far away. We spoke with them frequently; they were concerned but also elderly and too frail to make the journey to see him.
I have seen many frail elderly patients throughout my career. Aging is a great equalizer, often pushing us to a point where we become dependent on others for our care and needs with the hope that we may yet end our days peacefully, with dignity and love. Yet we too often fail our purpose. Mr M, elderly, black, frail was not only neglected physically, but robbed and left abandoned. How often is this happening to our elderly? But he was here in this large hospital, where those who had worked with him over the years, found their way to his bedside, offering support both physically and lovingly. They would stop me in the halls, asking about him. Though patient confidentiality prohibited me from saying much, I would reassure them. News of his situation had spread widely. They would respond by nodding, perhaps placing a light hand on my shoulder in mutual concern. We were his other family.
The salve worked. Several days later, the eschar was removed easily and, as I saw the ulcer underneath for the first time, I clutched his nurse, pained by what I saw. He had had a hip replacement in the same leg years ago, and we were looking at the head of it, covered with little tissue, and also foul-smelling pus, lots of it. We cleaned it, dressed it—still no pain! And I was grateful that he was unaware of the depth of his wound. The culture grew many harmful bacteria, and he was given antibiotics. During the next few days, its appearance was less frightening, and the plastic surgeon removed the covering of the sacral ulcer, finding it deep, but not all the way to the bone, a hopeful sign. We decided to ignore the exposed hardware. Time was needed for the healing tissue to replace the damaged.
However, he was very malnourished. The albumin, a measure of protein level, was very low, and protein is needed to allow healing to occur. His appetite was good, and he often ate most of his meals, fed by Eduardo and others. A psychiatrist had a long interview with him, letting me know that though he was able to discuss some things, his dementia was profound enough to prevent him from making important decisions about his care, physically and financially. Someone, family, friend or an individual hired by the state, would need to assume responsibility for his care.
The wounds very slowly improved. It became time for me to leave my service and prepare to give a handoff to the next physician who would care for him, as is the common practice in hospital medicine. His condition remained tenuous but hopeful. The hip specialist was going to give an opinion the next week, after the wounds had had more time to heal. But he remained bed bound. I had become involved in his day-to-day care, focusing on the wounds, the malnourishment, the bowel habits. I did not step back and look at the whole picture. I wanted that wound to heal, for him to get stronger, for that appetite to turn into nourishing energy that would allow this to happen. I did not imagine what his life might look like in one year, didn’t think about the possibility that he might never walk again.
On my last morning with him, I opened his electronic chart, and stared at the place where the room number listing for him should be. It was BLANK, which happens when a patient has been discharged or has died. “Wait! What?” I thought. “Had he died during the night and I not been told? “ I hurried upstairs to his room and found him waiting for me, with his broad smile. My heart pounding eased as I held his hand and he asked, “How are you doing today?” The unit assistant, a sweet, dedicated person, sat at the computer, tediously going through the steps to readmit him in the electronic medical records. With a red face, she told me she had retraced the steps that had led to his Inadvertent discharge, discovering she had been the one who had made the error. She had never done something like this before. I hugged her, telling her not to worry. We all had our stories of challenges with the ubiquitous computers. It was only later that I wondered about this strange occurrence, thinking. in the sometimes superstitious way that health care workers can do, that it may have been a foreshadowing or a preparation for what was to follow.
I said goodbye to Mr M, letting him know a new and wonderful doctor would be seeing him in the morning. He smiled (oh, that smile!), thanking me for my care, as he had done every day. An hour later, his nurse called me, stating he wanted to know when he would be going home. “Not for quite a long time but let’s tell him hopefully next week; he won’t remember, and it may ease his concern. Had he confused my leaving with his own?
That evening found me very tired. It had been a long month. Sleep easily overwhelmed me. Often, at the end of a protracted period of time on the wards, I wondered about the patients I had left behind. They were in good hands, but still, I often parted from them rethinking, making sure everything was done, nothing missed, plans made. Sometimes I had a sense of unease when I left, worrying I may have not addressed a critical issue. I was usually able to compartmentalize these worries. But a subtle sense of unease only worsened. I woke in the middle of the night, nauseated with a headache. I tossed and turned, took Tylenol, slept, and woke only slightly better.
Even though I had promised myself not to look at any medical records, my persistent unease drove me to it. Opening the patient list from my phone, I found, yet again, Mr M’s blank room number staring back at me. My heart stopped, held its breath a moment. This time, I knew he was gone. I learned he had had a devastating gastrointestinal bleed, and despite gentle, heroic efforts, he had died during the night. I lay there, struggling with acceptance, grief and remorse. Had I missed a tell tale sign? I lay awake until the dawn slowly bloomed.
I have had the privilege to care for many patients in my over twenty-five years of practice. I have learned much from caring for them and am honored to have earned their trust. But once in a while, there is a patient who leaves a profound imprint in my life, and Mr. M was one such individual. As physicians, we focus on healing, helping our patients to be well, to not suffer, to have better quality lives. Sometimes this focus can be so intense, we may neglect looking at the bigger picture or whole person before us.
Mr M’s wish, his hope, was to be able to walk again and despite our best intentions and care, this was very unlikely. At the end of his life, he was surrounded by many who knew him, cared for him and respected him. In this big and busy city where I live a surprising portion of our elderly may be alone and friendless at the end of their lives, I am sad to say.
The day before his death, he had asked us, “When could he go home?” I know, from having been at the bedside of those close to their death, that this is not an unusual question. Home becomes a metaphor for a safe place or perhaps a passage. But I wasn’t listening. I had focused on the fix it; his hope of walking and my hope of fixing his wounds so that that would happen. For me his story has become a lesson about the broader goal of healing. We may not be able to fix the wounds of loss and abandonment, nor physical manifestations that can appear at the end of life such as severe pressure ulcers, but we can give sustenance by listening, by being present, by reaching out to hold a hand when asked, “How are you today?”