For the past eight years I have been conducting monthly seminars for Yale cardiology trainees entitled "Humanities in Cardiology." In these seminars we discuss issues relating to individual patient care, empathy, healing, and bioethics. As medicine becomes more technologic, impersonal, automated, data-driven and computer based, such sessions take on added importance. The seminar series begins each year with a discussion involving one's most memorable patient. Members of the group are asked to discuss the patient that has had the greatest impact on their thinking and approach to patient care. I initiate that first session by discussing H.S., my most memorable patient.
H.S. was under my care from 1981 until his death in 1999. He initially had a large heart attack that required urgent care and emergent three vessel coronary bypass surgery. Thereafter, he did well until 1995 when he experienced a second heart attack while on vacation. Following the second heart attack he developed progressively severe congestive heart failure, which ultimately led to his death at the age of 75. H.S. was a senior librarian at the Yale Music School. In this position he had played a primary role in negotiating bequests to the library which included donation of major works and papers of famous musicians such as Benny Goodman and Arthur Rubenstein, to name a few. He was exceedingly proud of this activity and frequently expressed his desire to write a memoir based on the experience.
Over the last three years of his life, H.S. became increasingly disabled. In early 1999 all current state-of-the-art therapy was exhausted. (This was before ventricular assist devices, newer medications and newer treatment strategies were available.) The outlook was bleak. He was becoming increasingly despondent. He understood all too well that he had entered life's final phase. Depression was evident in his facial expression, his voice and his general appearance. At the conclusion of his office visit in early February we gathered with his wife for our usual summary discussion. In the face of his physical and emotional deterioration, I tried to conceal my own concern and frustration. As a last resort, I handed him a signed prescription blank on which was written: "For Dr. Zaret, one set of memoirs." When he peered at the prescription his eyes glowed for the first time in many months and he smiled deeply. Over the next several months I saw H.S. regularly. On each visit he was animated as he described progress on his memoirs. During this period he looked remarkably better. His fallen spirits were replaced with a new energy associated with this new goal and new sense of purpose. In early April he arrived for his office visit, his face alight with a sense of profound satisfaction. Before we could begin talking he handed me the first copy of the manuscript of his memoirs. On page one he described our meeting the day I gave him his new prescription. The introduction also contained a photocopy of the actual prescription.
After his memoir was completed and distributed to his family, H.S. began readying himself for death. His condition immediately worsened. The temporary respite was now clearly over. He and his wife summoned their children from around the country for a final visit. He requested that his status be changed to "do not resuscitate" (DNR). If he collapsed or his heart stopped beating, he would not undergo CPR. We also had candid discussions about death and modes of death. I feared that he would die from progressively severe heart failure and pulmonary congestion, a mode of exit that would involve significant pain, discomfort and anguish. I offered him the option of turning off the defibrillator that had been implanted several years before to protect against a life-ending heart rhythm. Death from an arrhythmia would be quick and painless. He accepted doing this. On his last visit we said goodbye and hugged. He was scheduled to return two days later to have the defibrillator deactivated by placing a magnet on his chest. However, two hours before that scheduled visit, he died suddenly, peacefully and painlessly at home.
Caring for H.S. taught much about doctoring. H.S. showed how one can heal without providing a cure. Writing his memoir was his healing therapy. Healing provides a sense of well-being and makes the patient feel, at least in part, whole once more. Healing is interpersonal and not clinical; it is more art and skill than science. Healing addresses the patient as a person, rather than the patient as an expression of a disease. As stated by the great physician of the first half of the twentieth century, Sir William Osler: "Care more particularly for the individual patient than for the special features of the disease." Though written about one hundred years ago, the statement still rings true. We must treat the patient struggling with disease, not just the disease.
Whereas healing can be impactful throughout an illness, it becomes extremely critical as one approaches end-of-life. There can and must be other means of caring for individuals when conventional medical therapy can do no more. For H.S. this strategy involved producing his memoir; for others it will be other individualized efforts that provide renewed meaning and purpose to life at a time when life is ebbing. As stated by Atul Gawande in his recent book "Being Mortal": "I never expected that amongst the most meaningful experiences I'd have as a doctor -- and really, as a human being -- would come from helping others deal with what medicine cannot do as well as what it can."
I keep H.S.'s memoir with the image of my prescription in a drawer near my office desk. It is a treasured jewel that I often revisit. Throughout the course of a patient's illness, as physicians we must make use of every possible medical and non-medical effort to succeed as healers -- healing and curing, two distinct and very different threads of a complex medical tapestry.