Last Acts (eBook)

INTRODUCTIONSylvester Sylvester It was when I was finishing rounds in my hospital late one evening that I first began to think about how my patients should spend their time when that time was cruelly limited. I'd just spent what felt like hours trying unsuccessfully to wrap up a difficult conversation with Sylvester, an older man who had a particularly vicious form of renal cancer. That his cancer was so extensive when it was discovered was due at least in part to a colleague's talent for inventing benign explanations for the increasingly numerous symptoms that Sylvester brought to clinic every month. My colleague dismissed Sylvester's symptoms first as 'nerves' and later as 'old age' until they were explained, finally, by the cancer that would kill him. This was the second time that Sylvester and I had met, and again our conversation quickly descended into a protracted and dispiriting review of Sylvester's treatment options, which were limited, and the chance of success with each, which was essentially zero. We had been talking for well over an hour about his cancer, possible treatments, and even experimental protocols for which he wouldn't have been eligible anyway. The conversation had become like a juggling act in which clubs were replaced by phrases--'quality of life,' 'comfort care,' 'aggressive treatment'--that he and I tossed back and forth until, for me at least, they had lost their meaning. In fact, I'm not sure these terms ever had much meaning for Sylvester. His mind was clearly elsewhere, and that night, just as he had during our first visit, he kept circling back to his missed diagnosis with a predictability that was becoming disheartening. It had grown dark outside his hospital room, which was itself lit only by a pale, flickering fluorescent tube on the wall just above Sylvester's head. The hospital ward had grown quiet, and even the shouts and metallic hammering of the construction site across 38th Street had been replaced by an eerie silence. And any remaining hope I had for a resolution to our discussion disappeared as I realized that Sylvester, who was Italian, began to lose his already tenuous grasp on English grammar and pronunciation as he became more emotional. He was working himself into a fit over his mistreatment, and our discussion swirled around and around, propelled by language that bore a diminishing resemblance to English. Finally, though, despite many misunderstandings, we seemed to be making progress across a river of circular arguments and recriminations. But just when I thought we had succeeded in hauling each other out of the other side, Sylvester stopped me with a question that sent us right back to where we started: 'What I do now?' I shrugged--what choice did I have?--and waded back into a discussion of treatment options. But he stopped me again, in English that was suddenly so clear it was hard to imagine our past hour of missed communication and said, 'No. No, I mean, I have no time left. What I do?' I wish I could say that this question--the most significant one he had asked me in our short but intense relationship--led to a meaningful discussion and let us connect as we hadn't before. But no, I dodged it. Just as most doctors would, I think. How should Sylvester spend the rest of his life? What sort of a question is that for a physician? He should ask his wife, perhaps, or their children. Or his priest. Or maybe this question was something he just needed to work out for himself. But I was stunned that he would ask me. I was also reluctant to answer because I was, suddenly, in new territory for which I didn't have a map. And that is...