It's a Relative Thing

Oh, the mea culpas of medicine -- and there are so many.

As a long-time practicing physician, I have let my guard down many times in situations I would have preferred to sidestep, e.g., taking care of relatives and neighbors.

I once had a venerable great-aunt somewhere about 85 years old at that time. For years, from the time I was an adolescent boy, she would constantly intimate to me how she could hardly wait for that glorious day, the time I would have finished my residency and she could then presume that I was her primary medical doctor. As luck would have it, such an aspiration was benevolent for her, detrimental for me. However, her longings and fantasies came to fruition.

At 85, her only medical problem was degenerative joint disease. So far, so good. About 6 months after I finished training, she acquired urosepsis, came into the hospital dehydrated, hypotensive, septic, etc. One can imagine the remainder of the narrative. She lapsed into adult respiratory distress syndrome, required ventilatory support and soon sustained a pulmonary embolism. Her APACHE score was dismal. Most 85-year-old patients would have rapidly succumbed in this type of exigency. But, my aunt, who was very tenacious, had borne and raised seven daughters, including a pair of twins, and her final child, a long-sought son. She would prove equally resolute when it came to life-threatening illness. Miraculously, after days and nights of arduous work, family conferences (mine), meeting my male cousin from California, whom I had never met (he came to town to be at her deathbed), my aunt survived despite my care.

I was very scrawny then, but I must have lost a badly-needed 10 pounds just taking care of her. She was a precise example of high Medicare expenditures in the days when such excessive care was limitless, and obtaining code status was far into the future. I had finally convinced her befuddled children that Aunty Anna was doomed and to let her go. But as I said, the hard-working immigrant from Europe operated on a totally different agenda.

She was slowly weaned off the ventilator, did wonders on anticoagulation and the potent combination of the newly-marketed cephalosporins and aminoglycosides. She lived! Of course, I thought she had little recollection of all the antecedent events by the time she was transferred out of the ICU.

A few days later, as I entered her room, I felt a sense of doom and failure in the air. I was correct. My aunt, who had a prosthesis for one eye, habitually used her intact eye as a weapon of derision, retaliation or whatever. I was never quite positive which eye was the functional one, but that morning its glare quickly told me.

"You're fired!" she said. "From what?" I asked. "I don't want you as my doctor anymore. It won't work." I was humiliated, surprised, disillusioned and ego-deflated. At an inexperienced, tender age I could not comprehend what she meant, or why. I had assumed her illness had been so severe that she was totally amnesiac of all the preceding events.

"You can't do this to me, Tante," I implored her. She replied that she wanted a seasoned, more mature doctor. My ego shrinkage was nearly unbearable. How could she do this to me, I thought to myself. Had some previous cryptic or repressed thought entered her mind? Had she remembered the fist fight I had with another male cousin when I was 12 and we had broken her porch swing during the rumpus? Or had she recalled my use of an erroneous German expression one day at 14 when I thought I was being complimentary, but had actually blighted her?

Currently, I have a similarly elderly patient with chronic obstructive pulmonary disease, ventilator-dependent, in and out of the ICU. She's strong-willed and Irish. She has an equally strong-willed son and daughter who cannot grasp the reality of their mother's precarious state. When I basically felt I was going to be fired from her case because of an inability to spawn new alveoli for her, I had several flashbacks to Aunt Anna.

Aunt Anna was not trying to humiliate or deprecate me. She probably knew how sick she had been. What she was really informing me was the same objective the Irish lady was proclaiming: "I never really wanted to go through this illness; I'd rather have died. Why were you and the family so complicit in doing the opposite of what I wanted, especially when I was too infirm to tell you? I was also trying to spare you the anxiety and agony of caring for me in such circumstances." (my interpretation) I didn't comprehend it so much then, but I do at this time.

My Aunt rather healthfully survived another 10 years, never queried me on a medical question again, nor did I ever go beyond asking her how she felt. Something that just didn't harmonize then registers vividly now.

The emotional affinity to a relative can potentially be risky. At the same time, the addition of a serious illness with all of its ramifications in dealing with a relative can be a cataclysm waiting to transpire or to be evaded. They may add up to a sequence of mea culpas.

"Reflections" is a collection of essays by the health professionals of the Medical College of Wisconsin.