Ten years ago I was sitting in my office seeing patients. The nurse asked me if I could squeeze in AA – he had just shown up at the front desk and wanted to see me. I agreed, and he and his wife came to the room.

AA was 15 months from what we thought was successful surgery for lung cancer. He had presented with an acute bronchitic attack and something made me get a chest X-ray. That X-ray showed an early lung cancer. I referred him to Thoracic Surgery. He was a good surgical candidate and we thought he was cured.

His thoracic surgeon saw him every 3 months, getting repeat X-rays. His most recent X-ray had shown recurrence. The surgeon told him that she could not operate on him again, and referred him to an oncologist. The oncologist give him a choice between chemotherapy and supportive care. The patient choose supportive care, and in the patient’s opinion, the oncologist seemed to lose interest. He came to my office that day to tell me the story (no one had kept me informed).

He actually started with a most unusual request, ‘Will you be my doctor?’ The question astonished me. As I quickly told him, I am your doctor, and will remain your doctor.

AA had started seeing me about 5 years prior to that incident. He was a prominent person in town, now aged 77. He had had a good full life. We talked for some time at that first visit.

While I cannot remember the precise details, I do remember the gist of our planning. AA wanted dignity until the end. He wanted to remain lucid as long as possible. He did not want any heroic measures. At that visit, he cried and I consoled. We discussed advance directives and made plans. I scheduled him to return in 3 weeks.

Over the remaining 4 months of his life I probably saw him 6 times. We had long visits and just talked about ‘stuff’. He was a most interesting man, and loved to tell his stories. His first project was to produce an autobiographical audio tape for friends and family. He achieved that within the first month.

His wife and daughter (from a previous wife) gave him outstanding support and strength. One incident sticks in my mind.

During this time I was being recruited by 2 medical schools. I finally decided to move to my current school that spring. I took a trip here one week for 2 days (making plans to start). The next day I was in my academic office handling the details of severing my relationship with my former institution. Given the whirlwind of my interviewing, visits, and pending move, I forgot my beeper at home. That afternoon I got a telephone call that AA was in the hospital.

I went to visit him to find out what was wrong. Apparently, he started feeling poorly, tried to call me, finding me out of town then called the surgeon. She admitted him and let her resident and intern care for him. He had a rapid heartbeat (due to a superventricular tachycardia), so the surgical housestaff called the electrophysiology service. They gave him some medication to slow his heart rate, and put a monitor in his room. The monitor beeped incessantly.

Now he was in a special section of the hospital known as the ‘Pavilion’. He had two rooms – so the family had a sitting room. I go in and everyone is crying. The family explains that he is frustrated because he does not want a monitor or IV fluids. I go to see the patient.

He quickly explains his frustration. He tells me that he is ready to die, but he does not want to die with an IV or a monitor. He wants to die at home with his loved ones around him.

As I assess the situation, I note that while he might die that night, he might stabilize, regardless of our therapy. Fortunately, he had no pain or other discomfort.

I quickly took over the situation to the relief of the patient, family and nurses. I wrote orders discontinuing the IVs and monitors. I wrote a long note in the chart explaining what I had done, and making clear that I would accept the patient on my service if thoracic surgery desired such. It was 6 p.m

At 7:30 p.m. I was starting dinner, when I received a page to the hospital. Answering I found the surgical intern on the phone. He seemed frantic and nervous. His resident had apparently told him to call me. He said ‘My resident said that if we can’t do anything for the patient, we would have to transfer him to your service’. I was astonished because my note stated clearly that I would willingly accept that patient. But even more, I knew that I was doing much for the patient. I wanted to teach the intern and resident, but knew by the intern’s tone that they were not ready for this important lesson. I told him that I was glad to take responsibility for the patient (my note had made that clear). I discharged AA the next morning to the relief of all.

AA lived another 2 months. He started to deteriorate soon thereafter. Fortunately excellent hospice care made his final days fit his dream. I remember the last time I saw him. I visited his house, and talked to his wife. He was already stuporous, but comfortable. I did not have anything medical to offer, yet my visit helped the family and helped me. He died 3 days after I moved.

Later that month I received a wonderful and cherished note from his daughter. She thanked me for the dignity with which his death occurred. She thanked me for caring about his humanity more than his disease.

That was 1993, and I knew little about palliative care. I am now exposed to excellent palliative care daily, as we have one of the superior programs in the country. In reflecting about AA, I probably could have made him even more comfortable if I had known more.

The Center to Advance Palliative Care (CAPC) is a resource to hospitals and other healthcare settings interested in developing palliative care programs. CAPC is a national initiative supported by The Robert Wood Johnson Foundation with direction and technical assistance provided by Mount Sinai School of Medicine. We are fortunate to have an active aggressive palliative care program at our VA hospital. My housestaff and I are exposed to these principles daily.

This brings me to the ethical dilemma that I suggest in the title of this rant. Given a patient with no reasonable chance for recovery, is paternalism acceptable? How do we provide humane compassionate care when we as physicians understand the risks and benefits of treatments in a more complete way than the patient does? A recent patient on my service may illustrate this point.

Mr. S. is a 74 year old gentleman with advanced dementia. He has contractures and does not communicate at all. He came from his nursing home because of a volvulus, which the GI fellow reduced in the ER. The nursing home had him scheduled for a PEG tube placement that week. For those who are not familar a PEG tube is a feeding tube that goes directly into the stomach through the abdominal wall. I have a visceral reaction to the general concept of PEG tubes, understanding that they are worthwhile in selected circumstance.

His 99 yo mother had verbally agreed to the PEG tube, because the nursing home had asked. We (my resident, interns and I) did not agree. We involved the palliative care physician and evaluated the patient carefully. He (with my resident) called the mother and had a long conversation about the patient. He directed her towards comfort and minimizing suffering. He acted paternalistically with these woman who clearly wanted direction. We discharged him to hospice care the next day without a feeding tube, either nasogastric or PEG. We expected him to die within the week.

Many situations call for some degree of paternalism. I would argue that palliation must combine patient autonomy with paternalism. We must understand the patient’s goals and desires even if he (she) can no longer communicate them. We generally guide the patient’s family towards comfort. In many ways, achieving comfort represents the ultimate medical achievement. We want our patients to die with the same dignity that they want. If that requires paternalism, then we should choose it.

Thank you AA, for you taught me much. I try to bring your lessons to every dying patient. You live in my memories.