Borders without Doctors.

“WHERE WERE YOU? Andy has asked to see you several times,” my friend Karen (one of our nurses) greeted me as I walked into our Palliative Care Unit. “Why? What is bothering him? Is he in pain?” “No! Just wants to see you, I guess. He is transitioning you know . . . ” Transitioning is a euphemism for active dying often used on our unit. “Have you called his family yet?” I asked, knowing full well that this would have been done as a matter of course. Karen did not bother to dignify my question with a response other than to give me one of her “you-poor-doc-on-training-wheels” look. Andy was a 52-year-old engineer with metastatic non-small–cell lung cancer who had been admitted to our unit a few weeks ago for terminal care. A pragmatic engineer to the core, he closely supervised all details related to his dying including his own funeral arrangements and financial care plans for his beloved wife and two adult children with immaculate engineering precision. Maybe because of our common interest in physics, Andy and I had struck a great rapport and we often indulged in geekspeak about transistors and transformers. “Why this sudden and uncharacteristic urgency to see me?,” I wondered walking into his room. Per nursing all his symptoms were well palliated. We had done a couple of family meetings and all the stake holders seemed to be on the same page. When I walked in, Andy was awake and alert sitting up in bed and comfortably propped with a couple of pillows. “Good, you are here!” he greeted me “I was afraid that I was not going to be able to pull this off” After the initial pleasantries, I launched into a quick interval history and physical examination that Andy patiently tolerated. “Bed bound, very weak, stable vital signs, but no overt signs of active dying . . . the prognosis is probably in the order of days. . . . ” I categorized Andy mentally. Thus reassured that I was not missing any major medical happening, I turned toward Andy when he requested gently, “Why don’t you go grab a chair and sit down? Hate to ask you to bring the chair, but I am too tired today.” Why was he asking me to bring in another chair when there were two perfectly good empty chairs in his room that I had used numerous times in the past? As I looked in askance at the two empty chairs near the window, Andy perceptively followed my gaze. “Oh yeah! Doc, I want you to meet my folks,” he said waving airily toward the empty chairs. “Your folks? Are they in town? But I thought you said that they were d . . . ” I swallowed the last word hastily. I recalled that Andy was an only child and that his parents had died many years ago. I instantly went into the medical mode and started barraging him with the typical orientation questions, “Do you know where you are? What year is this, what day, what date . . . ?” “I am at the Palo Alto Hospice Unit, today is . . . ” he rattled out the day, month, and year and finished with “and you are my doctor and you specialize in Palliative Care.” Now, looking a touch impatient, Andy said urgently “Doc! Listen, I think it’s time.” “Time for what, Andy . . . ?” I said in my best humor-thepatient voice. Meantime, my mind was busy formulating a differential diagnosis. The patient was acting strange . . . but he seemed alert and oriented . . . was he going psychotic on me? Delusions? Hallucinations? Maybe he is on too much morphine. Or could it be brain metastasis . . . I have to scan his head. No . . . no . . . That is silly. What am I going to do with the imaging results? No one was going to touch him, given his present condition. OK, might be best to curbside psych to be on the safe side and . . . “Doc, doc . . . ” Andy insistently interrupted my internal monologue. “Listen . . . We don’t have a lot of Pioneers in Palliative Care