Power, Lorena

Mr.  Mackay was a very tall man.  If he stood straight, he would tower over us all, but he often hunched, trailing behind Effie.  He had large, strong hands.  I imagined he earned his keep with those hands. That he had somehow, always provided for his family that way.  Effie has become much frailer over the past months, often tired and tearful, she remained as pragmatic as ever.  She told me, "He'll die in there, of a broken heart - if he doesnt get home, he'll die."

I met this couple in the spring of the year.  They walked into my office - her ushering him forward, guiding his every move, dictating when he would talk, listen, or move to the bed for his exam.  And he obliged.  He never would complain.  Effie was always clear as to what they needed.  Regardless of my incessant need to practice primary care, they were from a different generation.  They wanted none of that.  Their complaint was simple, to the point, and persistant.  He needed his puffers.  It took me 3 office visits to learn that when they asked for a prescription, they were asking for samples.  I also learned that they rode the bus to my office (more a rarity in Newfoundland weather than the norm), and that they had been married for 69 years (since Effiee was only 15 years of age).  They never spoke of hardship or heartache - but were quick to tell me they were doing fine at home.  She never spoke of his dementia.  They lived on their own and still managed to tend their vegetable garden. 

I began to wonder if it was possible that she didn't see what was so obvious to me.  Did Effie know how Mr. Mackay's memory was?  That he would progressively deteriorate?  Did they have a plan?  I questioned her ability as a caregiver, I challenged her memory.  And she passed.  In my quest to follow up, I tried to guide some of this conversation.  I did learn that they wanted to always be together - whatever "home" they would retire to, they wanted to be sure that they would not be separated.  I was failing to prepare them for what might come.

Their days went on and on, getting the bus, getting their groceries, preparing their tea, looking through the window at the turning leaves, and chatting about the weather.  Before the final leaves had fallen, Mr. Mackay developed a kidney stone.  He wasnt able to tell Effie what it was - he wasn't able to tell her it was pain.  He had no words, just frustration.  He couldn't say pain, he couldn't say where, and he couldn't be examined, and with that, he was admitted.  The pain was easily managed - but his behaviour was unpredictable.  Confined to four walls with nothing familiar, his confusion escalated, his delerium set in.  He spent more and more time in bed.  Without Effie at his side, he was often chemically sedated to keep him from wandering - for his safety - and for the safety of others.

He remained on a constant one-on-one observation for weeks.  As Christmas approached, despite Effie's yearning - she was not able to care for him.  After progressive decline in mobility, he had become more and more dependent for all of his ADL's.  His behaviour was too erratic, too unpredictable for Effie's frail frame.  I couldn't help but wonder if those behaviours would improve if he could just return to his familiar environment where Effie could say, 'button your shirt, pull up your pants, drink your tea, get in the bath, now George.'

Unfortunately, in this situation, in this society, this was too big a risk to take.  Effie had no supports, she wasn't able to imagine a back-up plan because she couldnt imagine that George wouldn't oblige her.  Effie sat crying, telling me he would die in that bed.  That he would never make it to long term care. That he would die of a broken heart.  But, there was no bed.  There was no bed anywhere.  And so, he sat.  He sat and he waited.  Confined to those four walls.

Over the harsh cold winter months, a strapping 90 year old gentleman became frail.  He developed influenza and then the dreaded c difficile.  Despite his pulmonary fibrosis and even further isolation (our unit was on quarantine), he responded to treatment - prolonged periods of antibiotics and then withdrawal of those antibiotics.  Delirium was always around the corner.  A sign of his illness was the sedation he required the night before.  All the while he remained on intermittent constant observation and the only questions he asked were  ‘when can I go home and where was Effie?’  Despite his delerium, he had many moments of clarity.  On a stormy day, he would ask me if my little boy had school and if my winter tires were good enough for the highway drive.

Mr. Mackay recovered from these ailments only to develop another nosocomial infection and spent his last hours short of breath.  He was distressed.  He may have been having a MI, he may have had a pulmonary embolus - but he was beyond most medical interventions.  In the absence of family, I fear I hesitated to allow his care to be comfort measures only.  It's always that fine line between medical and palliative that I find so difficult to navigate.

And all I could think of was that she told me so.  Mr. Mackay died waiting, waiting for a bed in a place where he could walk freely.  Where his long lanky legs could roam - and his large hands could be busy.  Where he would have been safe, with Effie.  Where I believe he would have settled.

I'm not sure if Mr. Mackay died of a broken heart or a causalty of our geriatric crunch.  I don' know. 

And I'm not sure how to fix this.  But, George and Effie deserve our effort.

Theme: Community | Communauté
Theme: Death and Dying | Décès et le mourir
Theme: Family | Famille
Theme: Health Care Delivery | Prestation des soins de santé
Theme: Relationships | Relations

Stories in Family Medicine | Récits en médecine familiale [Internet] Mississauga ON: College of Family Physicians of Canada. 2008 --.




Copyright © 1996-2018 The College of Family Physicians of Canada