{"id":1343,"date":"2013-10-11T06:33:09","date_gmt":"2013-10-11T06:33:09","guid":{"rendered":"http:\/\/jacobimed.org\/NS\/?page_id=1343"},"modified":"2013-10-11T06:33:09","modified_gmt":"2013-10-11T06:33:09","slug":"tobacco-tulips-and-terminal-care","status":"publish","type":"page","link":"https:\/\/jacobimed.org\/old\/ambulatory\/intern-ambulatory-block\/spring\/end-of-life\/tobacco-tulips-and-terminal-care\/","title":{"rendered":"Tobacco Tulips and Terminal Care"},"content":{"rendered":"

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Articles in PubMed by Author:<\/strong><\/span><\/p>\n\n\n\n\n\n\n\n\n\n\n
\u00a0\"\"\"\"<\/td>\nSirmon, M. D.<\/a><\/span><\/td>\n<\/tr>\n
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\n<\/span><\/p>\n

ON BEING A DOCTOR<\/span><\/span><\/span><\/span><\/h4>\n

Tobacco<\/span><\/strong>, Tulips<\/span><\/strong>, and Terminal Care <\/span><\/span><\/span><\/h2>\n

\"\"<\/a> Maryella Desak Sirmon <\/span><\/a><\/p>\n

<\/span><\/span><\/span><\/p>\n

15 November 1993 | Volume 119 Issue 10 | Pages
\n1042-1043<\/strong><\/span>
\n<\/span><\/span><\/span><\/p>\n

 <\/p>\n

\n

Seventy-two hours was
\na long time. But soon the conflicts wouldbe resolved. While John’s
\nbody struggled for breath and hissoul struggled for eternity, she
\nconsidered the internal conflictshe faced. What role should she
\nplay? Doctor? Daughter? Couldshe somehow be both? As she
\ncontemplated his death, memoriesof his life and their shared bonds
\ntrickled in. She reachedacross and held his hand and automatically
\nchecked a radialpulse for rate and rhythm.
\n<\/span><\/span><\/span><\/span><\/p>\n

John smoked–a lot. Mostly back when cigarettes and martiniswere
\nstill fashionable and Ronald Reagan’s face adorned Chesterfield
\n<\/sup>posters. Early years on the farm that his immigrant father had
\n<\/sup>dug out of the Pennsylvania countryside were filled with
\nresponsibilityand love. Childhood dreams were born in a one-room,
\nclapboardschoolhouse with eight grades huddled around a coal stove.
\nTheteacher, fresh from the Pennsylvania Normal School, gave
\nJohnhis first taste of books and cigarettes. Neither one seemed
\n<\/sup>dangerous at the time.
\n<\/span><\/span><\/span><\/span><\/p>\n

Then came that special girl. But her matriarchal Southern mother
\n<\/sup>did not approve of the damn Yankee. Although she banished him
\n<\/sup>from her house and her daughter, she could not stop the letters
\n<\/sup>and the secret meetings. Soon the two young lovers stole away
\n<\/sup>to the church up the street, picking up the required witnesses
\n<\/sup>along the way. There they etched their love into the county
\n<\/sup>registrar’s book and eventually into the old lady’s family Bible.
\n<\/sup>
\n<\/span><\/span><\/span><\/span><\/p>\n

With Pearl Harbor, life settled into a happy routine of marriage,
\n<\/sup>postponed dreams, and ration books that doled out cigarettes
\n<\/sup>and sugar. Postwar days saw a good job as a machinist, promotion
\n<\/sup>to shop foreman, a new baby girl, and a sense that some dreams
\n<\/sup>could come true. Then came the angel of sudden death for his
\n<\/sup>beloved wife. Her progressive mitral stenosis from old rheumatic
\n<\/sup>disease brought her to the University hospital for one of the
\n<\/sup>first commissurotomies, but not soon enough. At 46, he was left
\n<\/sup>with his daughter, his books, and his Camels.
\n<\/span><\/span><\/span><\/span><\/p>\n

His world now centered on this little girl, who was both the
\n<\/sup>remnant of his love and his life. He moved next door to thebig
\nwhite-columned house of his mother-in-law. There she andtwo widowed
\ndaughters, who had returned to the only home theyhad left, carefully
\nwatched over the child. Yes, there weredays the little girl missed
\nthe presence of a woman she barelyknew. But most days she was far
\ntoo busy growing up in the safetyof a father’s love to be disturbed
\nby such things.
\n<\/span><\/span><\/span><\/span><\/p>\n

As she grew, she shared John’s passion for books and listenedwith
\nher heart as he taught her compassion and integrity. Schoolpassed
\nquickly and easily. She basked in his paternal pride.Then she
\ndeclared her intention to apply to medical school.The family told
\nher that Marcus Welby was a figment of sometelevision producer’s
\nvivid imagination. But her father’s piercingblue eyes just smiled.
\nHe reassured her that sensitivity andscience were not mutually
\nexclusive. Armed with his confidenceand the innocent courage of
\nyouth, she soon conquered medicalschool, residency, and fellowship,
\nand returned home to theUniversity. The relationship with her father
\nchanged. AlthoughJohn could never quite relinquish his little-girl
\npicture ofher, they now talked as adults. During long hours over
\ncoffee,they shared ideas. With her support he had quit smoking
\nduringher medical school years. But this decision was to come
\ntoolate.
\n<\/span><\/span><\/span><\/span><\/p>\n

Caring for him as a daughter and not a physician, she entrusted
\n<\/sup>him to Dr. Mike, her favorite pulmonologist. This triangle worked
\n<\/sup>well. John continued a restricted but independent life in his
\n<\/sup>own home, enjoying frequent visits from his two young grandsons.
\n<\/sup>During these years, her career matured uneventfully until she
\n<\/sup>was asked to assume the position of Coursemaster for the ethics
\n<\/sup>program in the medical school. Without hesitation, she said
\n<\/sup>yes. She had always been interested in ethics and she eagerly
\n<\/sup>greeted this challenge. Fearing some inadequacy that might hamper
\n<\/sup>her students, she immediately enrolled in graduate coursework
\n<\/sup>in bioethics and returned again to the books that she had always
\n<\/sup>loved. To enrich the offerings, she brought in physicians and
\n<\/sup>ethicists of different backgrounds to work with the courses.
\n<\/sup>The students met her enthusiasm in kind, and as students always
\n<\/sup>do if allowed, taught her. Soon her work expanded to include
\n<\/sup>housestaff education and often faculty as well. The problems
\n<\/sup>were rarely easy and often none of the alternatives were pleasing.
\n<\/sup>
\n<\/span><\/span><\/span><\/span><\/p>\n

Then the tobacco<\/span><\/strong> years began to catch up with John. The
\nbaseballgames with his grandsons were replaced by checkers. The
\npulmonaryfunction test results and arterial blood gases began their
\nslowdownward spiral. Finally, Dr. Mike suggested gently that
\nnowwas the time for home oxygen. John was skeptical and
\nreluctantto encumber what little freedom he had left, but was soon
\npersuadedby the relentless dyspnea that dogged his every step. He
\naskedher, “What do you think?” She hedged, “That’s what we have
\nDr.Mike for”. The Gemini twins of doctor and daughter battled
\ntoan uneasy truce. She arranged to be at his home when they
\ndeliveredthe system–a compressor for the house and a large liquid
\ntankto refill the portable canister. She listened closely as
\ntheyeducated father and daughter about how it all worked.
\n<\/sup>
\n<\/span><\/span><\/span><\/span><\/p>\n

John adapted quickly to his new appendage, and it could be found
\n<\/sup>trailing him up a ladder as he hung new curtains in his house
\n<\/sup>or under his car as he changed the oil. None of her elegant
\n<\/sup>persuasion could slow him down. “So what if I fall off the ladder
\n<\/sup>and break a hip? Maybe I’ll die quickly,” he would say. Only
\n<\/sup>his worsening dyspnea could slow him.
\n<\/span><\/span><\/span><\/span><\/p>\n

Then one Thanksgiving, John made his first of many journeysto the
\nmedical intensive care unit. The careful attention ofDr. Mike and
\nthe housestaff paid off and John slid home, bypassingany real
\nconsideration of a ventilator. Three months and three
\n<\/sup>hospitalizations later, John and his daughter sat in his room
\n<\/sup>talking when one of her favorite residents came in.
\n<\/span><\/span><\/span><\/span><\/p>\n

“You know, I think I would like to take a trip,” John said.
\n<\/span><\/span><\/span><\/span><\/p>\n

Not sure where this was leading, the resident replied, “Oh?”
\n<\/span><\/span><\/span><\/span><\/p>\n

“Yes, to Holland,” said John.
\n<\/span><\/span><\/span><\/span><\/p>\n

The resident shifted his weight on uncomfortable feet and said
\n<\/sup>“That would be nice. I believe the tulips<\/span><\/strong>
\nthere are really beautiful”.
\n<\/span><\/span><\/span><\/span><\/p>\n

“Maybe,” said John. “But mostly I would like Holland becausethey
\nlet you put people to sleep there like we do animals whenthey’re
\nsuffering”.
\n<\/span><\/span><\/span><\/span><\/p>\n

The resident’s eyes mirrored the apprehension that crept intohis
\nsoul. He rambled on about how John was a long way from that.The
\nolder man just smiled. His daughter, the doctor, thoughta long time
\nabout what he had said.
\n<\/span><\/span><\/span><\/span><\/p>\n

John went home, calm and stable again for a time. Then Dr. Mike
\n<\/sup>called: “John has discussed suicide with me and has made specific
\n<\/sup>plans. I think you’d better remove the guns in his house ifyou
\ncan without upsetting him”. Her father had collected andrebuilt
\nantique firearms for many years. His finest pieces weredisplayed in
\na gun case he had carved by hand. And so, whenJohn was away playing
\nwith his grandsons, she arranged to haveall the ammunition and
\nfiring pins removed and stored at herhouse. If John ever noticed, he
\nnever spoke of their absence.
\n<\/span><\/span><\/span><\/span><\/p>\n

Another month, another hospitalization. Again he cheated the
\n<\/sup>ventilator and made it to the floor. Then early one morning,
\n<\/sup>her phone rang. John appeared to be in respiratory failure and
\n<\/sup>in imminent danger of arresting. The resident had already called
\n<\/sup>Dr. Mike. Dutifully noting the do-not-resuscitate order on the
\n<\/sup>chart, the resident wanted to verify its accuracy.
\n<\/span><\/span><\/span><\/span><\/p>\n

“Yes, that’s correct,” she said. “If he arrests, you are notto
\nbegin CPR. You may go with inhaled beta agonists and othermeds, but
\nno intubation. I’m on my way”. Her calm voice maskedthe terror she
\nfelt in her heart at losing this special person.She drove slowly and
\ndeliberately; a selfish part of her wishedhe would be gone before
\nshe arrived, sparing her the inevitable.He was not. The medicines
\nhad worked their magic again.
\n<\/span><\/span><\/span><\/span><\/p>\n

Two more months and two more hospitalizations later, she continued
\n<\/sup>to think. Home was no longer an option. After his last discharge,
\n<\/sup>she had arranged around-the-clock sitters. John stayed at home
\n<\/sup>less than 24 hours. Whether from hypoxia or the blessing of
\n<\/sup>some unseen angel, John became more forgetful and understood
\n<\/sup>fewer details around him. After thoughtful consideration, she
\n<\/sup>chose a hospice program especially known for its respiratory
\n<\/sup>care. It was a hard choice, one made with her memory of his
\n<\/sup>previous wishes and not his mind now. Dr. David, the director,
\n<\/sup>was both geriatrician and a treasured friend of many years.The
\nstaff were efficient, caring, and concerned beyond her expectations,
\n<\/sup>but that could not stop the tears as she toured the facility.
\n<\/sup>Her promise of professional detachment withered and died.
\n<\/span><\/span><\/span><\/span><\/p>\n

The days and weeks stretched into spring and early summer, andshe
\nalmost believed John could get well and go home. Dr. Davidmercifully
\nsaid no. She came daily. John enjoyed the gardenwhere she often took
\nhim outside to sit. They talked, reminisced,and tried desperately to
\nhold fast to the moment.
\n<\/span><\/span><\/span><\/span><\/p>\n

Then came the yellow sputum again. The well-balanced trianglewas
\nnow without one of its points, so the two remaining decidedto forego
\nthe hospital and parenteral antibiotics and a ventilatorin favor of
\noral antibiotics and continued close attention torespiratory
\ntherapy. Without speaking it, they knew what thiswould mean. She
\ntelephoned her office to cancel outpatientsand lectures for the next
\nseveral days. Fortunately, she wasnot on service; her partners had
\nalready accommodated her father’sillness many times and she was glad
\nshe would not have to askyet another time. The students had just
\nturned in their finalexams from the introductory ethics course, and
\nshe carried thoseto his bedside as she sat and they talked and
\nwaited together.
\n<\/span><\/span><\/span><\/span><\/p>\n

As the hours passed, John talked less and she thought more.The
\nquestions she graded took on a haunting significance: defineand give
\nan example of microallocation and macroallocation ofhealth care;
\nshould health care for the elderly be limited–whyor why not;
\ndevelop two arguments for or against physician-assistedsuicide; is
\nphysician participation in active euthanasia compatiblewith the
\npractice of medicine in today’s world and justify youranswer;
\ncontrast three differences between the traditional Hippocraticoath
\nand any one of the modern versions studied in class. Shethought of
\nQuinlan and Brophy and Cruzan, of Debbie and herovarian cancer, and
\nespecially of Diane and Dr. Quill and thecovenants that bind parent
\nto child or physician to patient.
\n<\/span><\/span><\/span><\/span><\/p>\n

Seventy-two hours was a very long time. In the papers she held,
\n<\/sup>innocent young students argued the pros and cons of assisted
\n<\/sup>suicide and euthanasia. Before her eyes, John struggled and
\n<\/sup>fought for every breath. In her mind, she saw tulips<\/span><\/strong>
\nand heardthe echoes of his wish for a trip to Holland. In her
\nheart,she cried and wished for the courage to act.
\n<\/span><\/span><\/span><\/span><\/p>\n

Would it be so wrong to use the skills he had encouraged herto
\ngain? The battling forces she faced were not good and evil,but
\nrather the little girl who loved her daddy and wanted tostop his
\nsuffering, and the trained physician who wondered ifmedicine has the
\nright to assert absolute control over everyprocess of life. The
\ndecision to withhold John’s care was adefinable act with both an
\nintent and a soon-to-be-seen effect.A syringe of stolen morphine,
\neasily obtained and used compassionately,would also have intent and
\neffect. Could she truly say thatbetween these two acts there existed
\na moral difference of suchmagnitude that the scene before her was
\njustified? In the end,she was powerless against the person he had
\ntaught her to be.When the time came, she quietly held him in her
\narms and kissedhim goodbye. Then she rang for the nurse: “My father
\njust died.The time was 3:49 a.m.”.
\n<\/span><\/span><\/span><\/span><\/p>\n

<\/a><\/span><\/span><\/span><\/p>\n\n\n\n
Author
\nand Article Information <\/span><\/p>\n\n\n\n
\"\"<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n
\"\"Top<\/span>
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\nInfo<\/span>
\n<\/span><\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

<\/a>University of South Alabama
\nCollege of Medicine, Mobile, AL 36617.
\nRequests for Reprints: Maryella Desak
\nSirmon, MD, Division of Nephrology\/Hypertension, University of South Alabama
\nCollege of Medicine, 2451 Fillingim Street, Mobile, AL 36617. <\/span>
\n<\/span><\/p>\n

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\nCopyright \u00a9 1993 by the American College of
\nPhysicians.<\/a><\/span><\/span><\/span><\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

Search Annals: Advanced search \u00a0Home | Current Issue | Past Issues | Search | Collections | CME | PDA Services | Subscribe | Contact Us | Help | ACP Online\u00a0 Institution: Albert Einstein Coll Med \u00a0 Sign In as Member or Subscriber \u00a0 \u00a0 \u00a0Article \u00a0 Return to Search Result \u00a0 Table of Contents \u00a0Services….<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":1341,"menu_order":0,"comment_status":"open","ping_status":"open","template":"","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"class_list":["post-1343","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1343","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/comments?post=1343"}],"version-history":[{"count":1,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1343\/revisions"}],"predecessor-version":[{"id":1345,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1343\/revisions\/1345"}],"up":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1341"}],"wp:attachment":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/media?parent=1343"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}