Monday, February 14, 2011

Another Milestone

Among various items for which it is tedious to be Jewish, the adherence to the lunar calendar must rank relatively high. We're talking about a people who have won Nobel prizes in every field, far out of proportion to their actual numbers on this earth, leading the world in physicists, mathematicians, and astronomers. And they can't use a modern calendar? Leap months every few years? Please.

Its tediousness bothers me at this hour because tonight marks the end of my first year on earth without my father. That is, by the Christian, or Solar, calendar, call it what you will. And herein lies the problem: the official mourning period ended for me some several weeks back. But even then that wasn't the completion of a Jewish, lunar year, because for reasons which I am not especially curious, the mourning period ends at 11 months in Jewish tradition. Then there was the Jewish year marking...yet another date. And I am ignoring the two or three other periods of Jewish mourning, which include shiva (the seven days following the burial) or shloshim (the thirty days), each of which has its own particular rites & obligations. Fortunately, as I am just a hair shy of atheist, the specifics didn't trouble me a great deal, with the sole exception of the prohibition against shaving during the shloshim, to which I adhered, in what is perhaps a term not used in jest, religiously.

But in my spiritual clock, as it were, I always measured Dad's death by the date of February 15th. To hell with this lunar nonsense, I thought--I don't pay attention to the Jewish calendar in any other part of my life except to show up for High Holidays or Passover when I'm told. The truth is that I have not taken Jewish chronology into my bones, and the 11 months came and went without any reflection, without making a point to go to the synagogue to say kaddish (Pops could have cared less, which helps assuage my guilt in this respect), without any reckoning of any sort. But in my quiet moments over the past few weeks, I see his face in my mind's eye, I think about how much of my father's son I have become--against even my own expectations and understanding--and how this past year would have been had he been part of it.

Paradoxically (or, for those who know me, likely not paradoxically at all) I have found myself in these moments taking comfort in about the least respectful of ways, saying to myself things like it's almost been a year since Dad bit it or yep, he sure bought the farm when he went to get the mail. I have giggled with a certain childish giddiness of the magnificent tribute paid to Graham Chapman by his Monty Python alum and longtime collaborator, John Cleese: "he's kicked the bucket, hopped the twig, bit the dust, snuffed it, breathed his last, and gone to meet the great Head of Light Entertainment in the sky." On New Year's Eve, a friend asked a truly loving and caring question about how my mother has fared since father's death, and perhaps a bit too mischievously I immediately flipped back, "actually she's been doing really well. She's really risen to the occasion. Dad should have died more often."

I'm glad I said it as I not only think the line is funny, but I think Dad would have laughed at it. And I'm glad to have a laugh when I think about him even in death, as I loved to tease him in life, especially after I overcame my fears of this man whose quiet thoughtfulness intimidated the oft-loquacious-and-not-nearly-as-thoughtful-me for many years. But the mirth is short-lived, and the truth undeniable: my heart is broken. I do miss him, and doubly so as I tried to make up for lost time once I figured out exactly how to be his son, as well as the fact that I am as much my father's son as I am my mother's--something much easier to spot, for me as well as everyone else. For nearly four decades our similarities had escaped my notice; now I ruminate upon them often.

I write this tonight not to excessively hash over these details (though readers will kindly forgive for the little bit of hashing I have done above), but rather to write about the toughest reckoning of all surrounding his death. To wit: I experienced his death both as a son and as a doctor, and I remain undecided as to whether I've screwed the pooch. But let me explain a little.

My father had reasonably clear instructions in his "living will" that he did not want what we in the biz would call "heroic measures." That is, if, say, his heart stopped beating, he would not want anyone to start CPR or shock him or do much anything else. For an in-hospital strategy, that works fine, but Dad's heart chose to stop beating out by the mailbox for the condo association. A neighbor, who of course knew nothing of that living will, called 911. The EMTs arrived and were able to resuscitate him. I can't and don't blame anybody for "saving" Dad's life at that point. But after that things get murky.

The blow-by-blow of the next ten days is unnecessary to recount, but the gist is that he underwent a series of maneuvers designed to give him the best chance of not only surviving "the event," as we call it (it was almost certainly something known as Sudden Cardiac Death, though even that's a loose term), but surviving it "neurologically intact." My sense from the start was that we needed to get the tube out of my father and let him die. It wasn't that I didn't want him to pull through. It wasn't--or at least I think it wasn't--that I had seen enough cases of patients like this to know the steep odds he faced in having anything approaching a "meaningful" recovery. Rather, it was the knowledge that a ventilator isn't what he wanted! Yet despite this we had doctor after doctor, from the ICU attending to the PCP, continue to tell us to stay the course.

Several days of back-and-forth passed until I finally said that he would be extubated or I would leave, and my mother agreed. We approached the hospital and explained our position, said that we understood the recommendations of the doctors, but were no longer in agreement with them. The following morning my father's primary care internist relented and acquiesced to our demands--though not without a subtle parting shot where he said, after acknowledging our position, that "it's not something I would do for one of my family members." Dad was extubated that morning, and died a few days later.

And there's the rub for me. I spent a week trying to be such a good doctor and seeing the reasonableness of their point of view, as well as their medical management, that I may have forgotten how to be a good son in the process and fight for what my father wanted, which was to be left alone. (For what it is worth, I have no qualms with their medical management; as far as I am aware all of the doctors involved in his case made fine medical judgements.) In particular, I have spent much of the past year unclear if I have been furious with the loose ethics of Dad's PCP, who imposed his own ethics onto the situation without regard for Dad's wishes (which might be shorthanded as live at all costs), or if I am just disappointed with him and understand that he made a tough call with which I might disagree but hardly one that deserves scorn. And, since my identity is split between son and doc, I have vacillated on even whether I am angry, flinging myself into meta-analysis upon meta-analysis, or am just trying to manufacture anger on my father's behalf, since I see the quandary of the PCP, who pushed, pushed, pushed for us to keep him, and hope, alive. Not how I'd play it but totally justifiable from a medical standpoint. So am I a furious son, or a distant doc? Search me.

What fills me with dread is that I may be bringing that shit into a room when I admit patients on Friday nights. I am not Sir William Osler--while I think I am a very competent doc I have never quite been able to make medicine sing like a few of my fellow residents--but I do pride myself on my ability to communicate with patients and their families. If I have a strength, it is in helping families through the kinds of moments that my family went through one (solar) year ago. But I can't tell at the moment whether I bring that damned baggage into those rooms, and I don't know when I'll be able to sleep soundly knowing that I haven't let my own experiences get in the way of what I do very well, at least in my own opinion. Thus I am being tested but have no way of knowing the grade.

Until I can find some internal method of ascertaining my own emotional and intellectual response, a one-year anniversary can't serve as a marker for some kind of closure for me. Pops may rest in peace, but his son the doc continues to cope in the aftermath, wondering how he did as a son, wondering what it has done to him as a doctor.


  1. Billy,

    I'd have sent this in an email so it would be more private, but don't have an email. I hope that you will read this before posting it.

    If one suspects that emotional baggage would influence patient interactions then seeing a professional to talk with (NOT receive medications from) is strongly recommended. I see too many professionals who didn't unload their baggage soon enough and are now seeing me because of the consequences of that.

  2. Dr. Arpaia,

    Thanks so much for your comment; I hope you don't mind that I have "published" it because I think your point is worth airing to anyone who may read this.

    I not only agree with your contention that it's worth considering counseling if one has emotional baggage, I think that there's a good deal more than a father's death that can create such baggage. Indeed, I think every doctor has to always remind themselves to check their emotions at the door before seeing a patient, whether those emotions are borne out of a broken heart from losing a parent, or a morning spat with a spouse.

    Nor does it have to be of a personal nature: take a look at the exceptionally poor behavior of Dr. Jack Cassell, urologist from Florida, who was so incensed by President Obama that he advised any patients who voted for him to "seek urologic care elsewhere" ( Dr. Cassell as well may need to talk with a professional. Either that, or have his license revoked.

    Which takes my comment further afield than I had intended, but I did want to let you know that I appreciate your concern for--if I've read it right--me as a person and me as a doc. Please do forgive my reticence, however, to discuss publicly any help I may have sought, am seeking, or will seek on this or any other issue. Your point, however, is too important not to mention on the pages of this blog, and I thank you for it. Best, Billy

  3. Thanks for your reflections. And yes my concern was for you as a person and as a doctor. I only know you from your blog, but from that I have come to respect you highly. Be well.

  4. Let the record reflect that I have not bribed Dr. Arpaia in any manner.

  5. Hospitals and physicians consistently ignore DNRs and Living Wills. After my mother fought the good fight for years, when she was ready to go she meant it. Unfortunately, her children then had to fight to get what she wanted, and it made a difficult situation much worse than necessary.

    Personally speaking, I feel some of the better doctors are the ones who have been through a few personal medical battles - either with themselves or through a loved one - as it makes them at the very least more empathetic while helping a family steer through all the land mines. That said, there's a fine line between empathy and going off the reservation.

    Thank you for the wonderful post!