That Good Night

by Sunita Puri

  “Not that different, I think,” Dave responded.

  Spit it out, Sunita. Don’t wait for him to say it. “Dave, I actually think you have gotten weaker because your emphysema has worsened. You need more oxygen, you have lost weight, and you are seeing things that aren’t there because at times you’re getting very little oxygen to your brain. And if you got so sick that you needed to be back on a breathing machine, I’m not sure that it would help you now the way it did then. In fact, I think there’s a very high chance you’d never come off the breathing machine.” The words came to me easily this time.

  Dave nodded and looked down. “I didn’t know I might get stuck on that machine next time. But I still feel like it isn’t my time. I don’t feel that horrible right now.”

  “And that is what we want to try to maintain,” I told him. “I mean . . . it’s a great thing that you are not suffering, and I hope that I can help you feel the best you can for as long as possible. But at some point, you won’t feel as well. What if you got worse and you couldn’t do the things that are meaningful to you, like working on your brother’s house? What if you needed the morphine to stay comfortable and that meant you couldn’t drive your truck?”

  “You mean when I’m dying?” Dave asked bluntly.

  “Yes,” I replied. “When you are dying. Because if we don’t discuss this, I worry that you may get sicker before you have a chance to tell me what you want for yourself at that point. And if we don’t know, you may end up getting therapies like the breathing machine that you may not be able to live without because of how severe your emphysema is.”

  Dave looked down at his hands. “I was worried that they’re colder and they have that blue tinge,” he said.

  “Yes,” I said. “I was worried, too.”

  “So . . . I guess you’re asking me what I want if things worsen. Or when things worsen, I guess that’s what you’re saying. That’s a heavy question. I’m pretty sure I don’t want to die plugged into a machine. But I need to think on it more. If I couldn’t get out of bed and I couldn’t drive my truck and someone had to wipe my butt, I don’t think I’d want that type of life.”

  “You should definitely take some time to think about it,” I said. “Maybe we can talk more when I see you again in a few weeks?”

  Dave looked again at his hands and squinted. “What if you were in my shoes, Doc? What would you do?”

  As my months in fellowship passed, I couldn’t do my job without wondering what I would want in the situations I confronted daily, so I answered Dave honestly. “I’d think about who I wanted to be with and see, what things I might want to do. I’d think about the types of suffering I couldn’t deal with. I’d want to be at home, not the hospital. And I’d want to spend that time with the people I love, doing the things I can manage.”

  Dave nodded. “I’ll think about it, Doc. Thank you for bringing it up. I wouldn’t have,” he said, laughing and then inhaling sharply, his hands on his knees again.

  * * *

  When I thought of my grandmother, as I did so often after seeing Dave, I envisioned her with emphysema. I wish I could remember what it felt like to be mothered by her: How she held me close as we boarded a plane to New York, then Berlin, then Bombay, stroking my head and rocking me gently so that I wouldn’t cry. How she cradled me when I cried and gave me bottles of warm milk and slept next to me. How she gave me baths in a small bucket and wrapped me in baby clothes she sewed herself. How she sat me next to her in the small kitchen where she prayed in the mornings, reciting mantras and clapping her hands as she sang devotional songs. I wished I remembered her singing.

  I thought about my answers to the questions I asked Dave. If I had a few months to live, I knew I’d want to be at home in Los Angeles, near the ocean where I’d played as a child, with my parents and brother. But my life right now didn’t reflect anyone or anything I’d value at my life’s end. If I instantly knew I’d want to be with my family at the end of my life, why wasn’t I thinking about being with them now?

  I hadn’t lived near my parents since 1998. I left Los Angeles immediately after graduating from high school and attended college on the East Coast. I went even farther away afterward, moving all the way to Oxford, in England. Although I could have returned to Los Angeles for medical school or residency, I chose to move to San Francisco instead. I love my parents and brother deeply, but for many years I chose to live at a comfortable distance from them. I’d always assumed that I could go back to Los Angeles when my adventures were over, expecting to find my parents in perfect health, waiting for my return. I’d taken them for granted just as I’d taken my grandmother for granted.

  I have to go back to Los Angeles. My mind and heart spoke in unison, just as they had when they’d directed me to Connecticut and Oxford and San Francisco. But there was more. I’d started to recognize how entitled I’d been to assume that I would live a certain number of years, that my parents definitely had decades left because they were fit and mostly healthy, that my life would follow the expected linear trajectory of marriage, children, old age. In fellowship, I’d cared for so many patients my age or younger who were dying just when their careers were beginning, or shortly after they’d gotten engaged. People older than I was had assumed they would see their grandchildren’s births or take an around-the-world trip when they retired, only to be sidelined by an accident or diagnosis. I’d learned a lot of medicine in fellowship, but the most profound lesson I’d learned was that living required both humility and acceptance of the unexpected. At some level, I’d known this all along. And when I asked myself the same questions I asked Dave and my other patients on a daily basis, it was clear to me that my life up to this point bore no resemblance to the life I’d want if my time was short.

  While in residency, I’d borrowed two family photograph albums from my parents and recently found myself poring over the pictures as though I were seeing them for the first time. There was a photograph of my brother’s high school graduation, my mother in a lime green salwar kameez, my father in a black suit, my brother sheepishly smiling in between them. I hadn’t been there, opting instead to stay on my college campus and start an internship early. Another snapshot: my mother beaming in a pink sari, my father in an ivory kurta, raising a glass of red wine to toast their anniversary. I’d been in residency, too tired to book a flight to Los Angeles to attend their celebration just for that one day. There’s always next year, I thought at the time.

  As I leafed through the albums now, my absence stung me. The years had passed so slowly, and then so fast. I had put my family relationships on the back burner, chasing my dreams (or fulfilling their expectations?) at the cost of tremendous distance between us. I couldn’t forgive myself for privileging schoolwork over my relationship with my grandmother; I didn’t want to make the same mistake with my parents and brother. I opened my computer and began to search for palliative care jobs in Los Angeles.

  * * *

  Despite my many worries, Dave remained stable. Not well, and not improving, but not getting worse. He still gasped, and he occasionally hallucinated, but he began to eat a bit more after starting the appetite stimulant I’d given him. He had a little bit more energy to work on his brother’s house and make it to his appointments at the VA. “I tried the morphine one day, Doc, when I knew I wasn’t going to drive,” he told me. “I think it really helped. I didn’t feel like I was struggling when I took a bath. And I finally slept through the night.”

  “I’m so glad to hear that, Dave. It’s great that you tried it, so now we know that it works at this dose!”

  “I also thought about what we talked about last time,” he said, his face turning serious. “I really think that I’m still strong, Doc. But if it’s my time, I just want to go in peace, maybe in my own bed.”

  I was grateful that Dave broached this subject. “I hope it’s a really long time away, Dave, I really do. And please know that saying no to
machines doesn’t change the many other treatments you can get. Our plan would be to keep your breathing and fatigue under control so you can have the best possible quality of life. But saying no to machines at the end makes sense.”

  Dave’s face softened. “I’m glad to hear you say that, Doc. I was thinking maybe that no machines meant no treatment, no nothing, just letting me die like a dog. But I’m happy you’ll take care of me till the end.”

  I helped him to fill out a POLST form and told him I’d scan a copy into his medical record and give him the original to place on the wall of his warehouse. He promised to share the form with his landlord, who’d agreed to help make medical decisions for Dave if he couldn’t make his own.

  We discussed when moving into a nursing home might be the safest option for him, and when it might be time to enroll in hospice care. For now, he told me he could live with the shortness of breath and the occasional hallucination since he was still managing to meet his own needs. But if he became mostly bedbound and couldn’t get in his truck and drive, he’d interpret that as his body shutting down, and he’d want hospice care, probably at a nursing home if he couldn’t stay in his warehouse. “I know that I don’t want to be alone at the very end,” he told me. Dave acknowledged that it hadn’t been fun to have this discussion, but he was relieved to have made his own decisions about what he’d want at that point in his life. “It’s so hard, Doc, when your mind is sharp and your body is shutting down. But at least I have a little control over the end since we spoke about it.”

  * * *

  Exactly one year after I’d moved to Burlingame, I stuffed my clothes and books into two suitcases, filled plastic trash bags with even more papers and books, loaded up my blue Honda, and began driving to Los Angeles. I couldn’t believe that my medical training was done. I felt just as disorganized as I’d felt as a resident and fellow, but as of yesterday, I’d become an attending physician—a full-fledged physician who had completed her training. Though I usually blasted a hip-hop mix when I drove down Interstate 5 to Los Angeles, I began this drive in silence. Familiar scenes whizzed by: The water-starved brown fields alongside the freeway. Lines of almond and citrus trees on family farms. The black and brown cows feasting on lone patches of green. I left behind all the years I’d spent in the Bay Area, the years that passed so slowly and then so fast, just like the drive down the 5.

  When I parked outside my parents’ house, I realized it had been fifteen years since I’d been in Los Angeles in July. I’d forgotten just how oppressive the summer heat here could be. I wasn’t looking forward to unpacking my car. I only had energy to bring in one suitcase packed with the clothes I’d need for the rest of the week. The front of my parents’ home looked nothing like it had when I last lived here in my senior year of high school. The basketball hoop wasn’t atop the garage anymore, and shiny copper wind chimes swayed right above the newly planted succulents and lavender in the front yard. But this isn’t a visit anymore, I reminded myself. My childhood home was my home for the next two months, after which I’d move into the heart of Los Angeles and begin my first job as an attending.

  I set my bags down in the bedroom and noticed a new voicemail on my phone, even though I hadn’t heard it ring, possibly because of the poor reception on the freeway. The message was from Dave. On a whim, I’d given him my cell phone number and told him to keep in touch and let me know how he was doing. Even though I shared my number with a handful of patients over the years, most never called. I hesitated before listening to the voicemail and imagined that any number of scenarios could have prompted Dave to call. I stopped myself from jumping to the worst conclusion, since he couldn’t have left a message if he was intubated. I pressed Play. It was as though he were right there, in front of me in the clinic, pausing and gasping and putting his hands on his knees and telling me exactly what he had to say.

  “Doc, it’s me, Dave. I came in for my appointment today. I just met my new doctor, the one I guess is your replacement. Gasp. She’s kind of green, I guess. Still learning maybe. Cough. I just wanted to say I’ll never forget you. I wish you all the best of luck in your career. Thank you for everything you did for me. Cough. You don’t need to call back, I just, you know, wanted you to know.”

  I saved his message and pressed my phone against my heart. I looked out the window of my childhood bedroom at the guava tree and tomato plants and patches of wildflowers in my mother’s small garden. I listened to the pressure cooker hissing in the kitchen below, inhaling the scent of the garlic, ginger, and onion that my mother had chopped and stirred into my favorite daal. It was as though I were back in high school, just on the verge of leaving for college. Nothing had changed, though everything had. I wondered if I’d be here right now if I had not met Dave. I pressed the phone harder against my heart and wished I could thank Dave for everything that he actually did for me.

  Part 3

  INFINITY IN A SEASHELL

  Eight

  BEGIN

  I’d taken my first job as an attending physician at a hospital that was both new and familiar. A brightly lit, gray building with a large courtyard, the hospital rose above a busy Los Angeles intersection. It was part of the large medical group that my mother had joined when we moved to California in 1986. Though my mother had never worked at the specific hospital I joined, the hospitals in the group share similar architecture and furniture. The hospital’s motto, its logo, and the font of the signs pointing to the pharmacy and radiology remained unchanged over the years. I calmed my nerves by reminding myself that, nearly three decades ago, my mother walked into a nearly identical hospital for the first time, and it quickly became her professional home.

  Meg, a kind woman from the human resources department, had shepherded me through the process of applying and interviewing for this job. After I had mulled over and finally accepted the offer, she said, “Maybe this is a long shot, but a long time ago I recruited another doctor whose last name was also Puri. She was an anesthesiologist. Any relation to you?”

  “Yes! She’s my mother,” I said proudly, a wide smile on my face.

  “I remember your mother so clearly,” she exclaimed. “This was back when it was really hard to find a well-trained anesthesiologist, and I remember thinking we had to nab her!”

  Anesthesiologists were once in short supply and high demand, just as palliative care doctors are now. “Does she still have that long, beautiful hair?” Meg asked. I envied her memories of my mother, who’d cut her hair chin-length when I was young. I’d only seen her long hair in snapshots from family albums, generally from years I didn’t remember. “She cut it a long time ago,” I said. “Well, I am sure she is just as beautiful as she was then,” Meg responded before describing the details of my orientation day.

  I could feel my mother with me as I walked around the hospital lobby, studying the signs to the laboratory, radiology, primary care clinic, and cafeteria. I stopped by the cafeteria and found a breakfast station offering scrambled eggs and potatoes, no Grandma’s brownies or ice cream machine. I imagined that the overnight call rooms now had more comfortable beds, updated televisions, and computers, since all charts were now electronic rather than paper based, as they’d been when my brother and I visited my mother’s call room.

  When it was nearly time to meet my new team, I stopped by the bathroom for a few minutes of solitude. I inspected myself in the mirror.

  My dark hair, freshly washed and slightly wavy, fell around my shoulders. I wore an orange shirt with a floral pattern that you could see only if my white coat opened just a bit. The coat itself was pristine. I hadn’t yet had the chance to speckle it with the coffee stains or pen marks that always found their way onto my white coats in medical school, residency, and fellowship. I’d retired them all in one corner of my closet, my ID badge from each stage of training still clipped to its respective coat. The badge I wore today was the first one that didn’t list a year in training.

 
“Congratulations,” my mother said when she called me on my way to the hospital an hour ago. “It’s a very big day. The beginning of your career.”

  9:00 A.M.

  I meet my new team in a basement office lined with three workstations. Candy has been a palliative care nurse for several years and works closely with Brittany, the team social worker. I spend my mornings seeing patients with them here in the hospital, just as I did throughout my training. But I spend my afternoons driving to the homes of patients enrolled in hospice or home-based palliative care.

  Candy and Brittany welcome me graciously, pointing out a pile of snacks atop the small refrigerator in the office, as well as the bathroom around the corner. There are five new patients to see, Candy tells me. “Doctors here place the orders for a consult electronically rather than by paging us,” she says, “but you are free to call them and get more information about the reason they need our help.”

  Candy suggests that since I’m here only for the morning, maybe we should split up and she can see a few patients while I see a few patients. We could regroup after that. She and Brittany give me their cell phone numbers so that we can keep in touch throughout the morning. They tell me to concentrate on seeing the new referrals over the next three hours, reassuring me that they will see the other patients on our list.

  There are no typical days, I discover quickly. But an average day goes something like this:

  9:30 A.M.

  Maddy is my first patient. She’s sixty-eight, with metastatic pancreatic cancer, Dr. Lee, the hospitalist this week, tells me over the phone. I hear her pager go off several times in the first two minutes of our conversation. Maddy was admitted last night for fevers and chills caused by bacteria that had moved from her gut into her bloodstream. “She’s getting sicker as we speak. Her blood pressure is marginal. We could send her to the ICU, but given that she’s got metastatic pancreatic cancer, I don’t think that’s a good idea but haven’t been able to sit down and talk that through with the daughters. Everything happened so fast and I barely know the patient. Can you come soon? Her daughters are here.”