There is a black and white photograph on top of the bookshelf in my office of two old people just about to kiss.  You see them from the side, starting at the upper chest, her left shoulder and his right, and a blurry outdoor background, maybe they are sitting on a bench.  He is wearing a checked shirt and what looks to be an overstretched, frequently-worn button-down cardigan, probably brown or gray, like the ones my husband and father and father-in-law wear/wore constantly and that my sons would not remotely be caught dead in.  She has on a light mock-neck sweater, probably pink, with a chain around her neck decorated by a wedding band.  Both are wearing glasses, and an earring peeks out from under her mane of casually combed back, once red but now pure white, just-above-shoulder-length hair.  Hearing aids, if present, are invisible to the camera.  Her forehead is higher than his, but she is small-jawed, with fine wrinkles radiating from her eyes and the corner of her mouth.  Their noses are small, similar in shape, and no more than an inch apart, and two sets of lips are puckered familiarly as they prepare to meet.  He has not shaven for a while, and his once shaved or close-trimmed hair is at least a third of an inch deep in fuzz.

Their eyes are closed, and they are thinking only of each other.

I imagine that people coming into my office think this is a picture of my parents, but it is not.  These are the O’Briens.*  Dr. O’Brien was a colleague and patient, and his wife (I’m not sure I ever knew her as anyone other than Mrs. O’Brien, as this was back in the time when respect dictated the use of formal address with patients and families, especially when they were our elders) was his constant companion of fifty-five years.

Dr. O’Brien, now in his eighties, had had Parkinson’s disease for twenty years, and I had been his neurologist for ten of them.  About eight of those had been good years, but the last two had been more difficult, because of walking troubles, fading memory, poor bladder control, and the most disturbing thing—episodes of unresponsiveness.  I see this sometimes in late-stage Parkinson’s patients, daytime “Parkinson moments” where they appear to be deeply asleep and difficult or impossible to awaken.  Ten or thirty minutes later they are awake as though nothing has happened, but of course, a spouse or medical team witnessing such an episode for the first time would appropriately feel somewhere between concerned and frantic, and contact 911—paramedics—emergency room—cardiac unit—neurology consult—everything normal—discharge plan: follow up with the neurologist right away.

All these things had happened, repeatedly.  And I would have the same conversation with his wife.  She was in a wheelchair herself due to a leg amputation, and I had the impression that she had been too familiar with the wine bottle over the years. She was anxious, always pushing for another medication, asking why did he have these spells and what to do.  I had tried repeatedly but gently (I thought, hoped) to explain that while on the one hand, these spells reflected the general idea that Dr. O’Brien was in the later stages of his disease, on the other hand, any given spell would be self-limited and after multiple episodes, it might be permissible not to go to the hospital every time, or to ask the paramedics or emergency room staff to just check him over without necessarily admitting him.  She never seemed to understand this suggestion, or maybe she forgot.  Dr. O’Brien generally dozed lightly during these discussions.

One time that spring I saw him after such an event, and he looked grizzlier and more tired than ever before.  He had the look of distance and detachment that I have learned to recognize as a portent of the coming conclusion.  His wife was asking her usual same set of questions, so I did something I would not ordinarily do: I deliberately turned my back on her, looked Dr. O’Brien directly in the eye, and asked, “Are you tired?”

“Yes,” he answered.

“Do you want to continue going to the hospital every time you have a spell?”

“No, I really don’t.”

“Do you feel like you are dying?”

He nodded.

“Are you afraid of dying?  Are you uncomfortable?”

“No. I am ready.”

I turned back to his wife at that point and said, “This is not about you, it is about him.  He has had Parkinson’s for a long time, and his time is simply coming to an end.  He does not need to go to the hospital when these spells happen, but it would help for him to be in a place where someone could check on him when they occur.  And, please, let us work together to make these last days/weeks/months comfortable.”  Those might not have been my exact words, but with discomfort even now, fifteen years later, I admit to having used a rather blunt tongue.

It worked. Dr. O’Brien moved to a setting where he could receive nursing support over the coming weeks, and the hospice team became involved.  The children (ten of them) and grandchildren (double that) came, memories were shared, hospitals were avoided, and the comfort of a large family became apparent.

And then Mrs. O’Brien was suddenly diagnosed with end-stage cancer.  Always petite, she rapidly faded to a wispy shadow.  It was unclear who would die first, but in the end, it was Dr. O’Brien.  I went to the visitation, where I met the children and grandchildren, and stammered through the usual condolences.  “I hope he was comfortable,” I said to one of his sons.

“Didn’t they tell you?” he replied.

“No, what?” I stammered, worried.

“Well, you know that Mom was moved to the room across the hall from our Dad three weeks ago, and so they could see each other all the time.  Over the weekend, it became clear that he was dying.  We were all there.  She went to bed that night, because she was so tired, but she asked us to wake her up to be with him, you know, if he was going to go.  So, in the middle of the night, he was barely breathing, and you could tell, his pulse was slow, so we brought her in from her room.  She was sitting next to his bed and looked so sad.  We asked her—do you want to get in bed with him? And she nodded, I would like that. So I scooped her up, she hardly weighs anything now, and put her in bed with him.  And his breathing and his heart rate promptly increased.  You could just tell that he knew she was there!  They lay there together for a while, and after a while they both fell asleep, and so we brought Mom back to her bed.  He died that night.”

A daughter came up to me with a photograph.  “I want you to have this,” she said.  “My father always looked forward to his appointments with you, and we thank you for helping him through his years with Parkinson’s disease.  This is a picture of my parents that I took at about the time he went into the nursing home.”

I’m not sure what I said, but I do know that I cried all the way home.  I marveled at how fully and beautifully intertwined Dr. and Mrs. O’Brien had been for so many years, and felt honored to glimpse, perhaps at its best in this sad time, the large family that was the much bigger part of his life than the daytime hours we spent together as medical colleagues, or the small slice of years we shared as doctor and patient.  And I am not a religious person, but they were, and when Mrs. O’Brien died two weeks later, you just know that she found her love up there waiting by the gates for her, so they could complete their kiss and walk hand-in-hand once again.

*Names have been changed to protect the patient and caregiver’s privacy.

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