A Geriatrician's Gifts

Birthdays and winter holidays conjure up visions of gifts. This past year, I came to appreciate a geriatrician’s gifts on these usually joyous holidays. The year started with a celebration of my mother’s 90th birthday and retirement from more than 60 years of managing doctors’ offices. “Mama O” is known to many in the field of geriatrics because of her sale of cookbooks at the annual meeting of the American Geriatrics Society to support medical student research. My younger sister and brother, usually quiet and unassuming, totally upstaged me, an experienced public lecturer and storyteller. Marcy O presented a David Letterman–style “The Five Best Things I Love About Mama O” that brought applause mixed with laughter and tears. Unbeknownst to me, Lenny O is also known as “Lenny the Lizard,” a closet rapper who stunned our family and friends with a clever and touching “Mama O Rap.” One week later, a series of events began that helped me come to truly appreciate a geriatrician’s gifts. Marcy O, aged 54, underwent surgical excision of a groin mass. The diagnosis was well-differentiated squamous cell cancer with no node involvement. There was reason to hope. An expert oncologist told me that this is a rare vulvar malignancy—relatively easily cured in some people but one that can lead to rapid death in others. Marcy O fell into the latter category. I knew she did not have long to live when she developed new lesions while receiving chemoand radiation therapy. She quickly became too weak and uncomfortable to work. Single and never married, she moved into Mama O’s condominium in New Jersey while she continued treatment. In my 30 years as a geriatrician, I have seen two things devastate older people: loss of a driver’s license and loss of a child. Seeing Mama O, who lived for her children, watch her only daughter suffer for 8 months, then hold her hand during every waking moment for the last 2 weeks, was the most profound experience of my life —professional or personal. Lenny O, our sister’s best friend and closest confidant, became my hero during those 8 months. He sacrificed his professional and personal life to accompany and comfort Marcy O during her many doctors’ visits and hospitalizations. I visited briefly on several occasions, trying to tactfully offer a realistic prognosis, but the denial was strong. I succeeded in convincing Marcy O to execute a will and to sign a durable power of attorney for health care (DPHC). On August 6, my 60th birthday, Marcy O finally agreed to enroll in hospice. I was relieved that the denial was finally over. The hospice was an excellent one, but without my experience as a geriatrician, Marcy O would have died a miserable death. For the last week of her life, I was her intern, constantly on call. I assisted the hospice aide in changing diapers and dressings and slept in Mama O’s bedroom, adjacent to Marcy O’s hospital bed, setting an alarm for every 2 hours so I could titrate sublingual morphine and lorazepam to relieve her physical and emotional suffering. She died comfortably, knowing her family was with her, on August 16. Being able to use my professional experience to help my sister die with comfort and dignity is the best birthday gift I have ever received. During the months of Marcy O’s illness, my 91-yearold father’s dementia worsened. He and his second wife of 25 years did not believe in going to doctors, so when he began falling, I flew to New Jersey to perform a geriatric assessment. I found a gait disorder common in people with dementia and a loud systolic murmur. I told him about the murmur, but he wanted no further evaluation, so I led him and his wife through the process of signing a DPHC, in which he designated me as his proxy and, despite his dementia, clearly stated his wishes for no aggressive measures in the event of a serious illness. His falling stopped, and he was able to enjoy the summer taking short walks and swimming a few laps now and then, but on December 23, he was rushed to the hospital. I immediately contacted the emergency department physician, told her about his dementia, and faxed a copy of his DPHC. Evaluation revealed atrial fibrillation with a rapid ventricular response, critical aortic stenosis, and a cardiac ejection fraction of 10%. On Christmas Eve, he had a stroke. His physicians were good about calling me with updates, asking me if I was sure that I did not want to consider surgery, enteral feeding, etc., etc., and listening to my advice about treating his delirium. Two days after Christmas, and 2 weeks before his 92nd birthday, my father died peacefully with his wife by his side. His rapid death after From the Charles E. Schmidt College of Medicine, and Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida.