One Last Visit to See My Patient

The rain was coming down in torrents and my shoes were not up to the job. Nevertheless, I pressed forward along the soggy blocks. My 91-year-old patient and I had been together for some 20 years — honestly I’d lost count — so this was the least I could do.

Fibrotic lungs and a weak heart set in a 4-foot-5 frame of osteoporotic bones would not seem the stuff of stamina, but until recently, she was still making the grueling 20-hour plane trip back to the Philippines every autumn. She had bounced back from several stays in the I.C.U. even well into her 80s.

My patient’s daughters took exquisite care of her. It was clear that every medical issue was rigorously attended to, but it was also clear that she was abundantly steeped in love. It’s hard for me to remember a time when she wasn’t smiling.

Even as her body and mind grew more frail, she was unfailingly cheerful. At one visit to our clinic, I asked about her hobbies. She told me that she liked to sing along with hymns on the stereo. She sang one for me, easily the most mellifluous sound ever to traverse our hospital’s halls.

Eighteen months earlier, I had raised the issue of hospice care. The family was hesitant — they were very private people and didn’t want anyone in their home. But I suspected that they were also put off by their associations with hospice. For most people, the word hospice means “game over.”

My patient and her family agreed to give hospice a try. Within weeks, they were singing its praises. The hospice nurse visited weekly and whenever a clinical situation arose — a fever, pain, trouble breathing, a fall, — the nurse texted me and we could quickly figure out what needed to be done, and how to do it with the least hassle for the patient. Even though we weren’t pursuing “curative therapy” — her cardiac and respiratory disease were grave and irreversible — we were able to put out the little fires before they became big fires. The goal was always maximizing comfort.

In some ways, hospice care struck me as the original “concierge medicine,” where a whole team of players dedicated itself to the patient’s every need. This was the closest we could get to ideal medical care.

It didn’t escape me, though, that this level of care could only be feasible for a handful of patients. If every one of my hundreds of patients had my cellphone number and texted every time something came up, the system would collapse under its own weight.

Still, I was intensely grateful that this patient remained comfortable, happy, pain-free and able to remain in her home with her loving family. Just as the data predicted, she was living far longer than any of us would have expected, given her congestive heart failure and her severe respiratory disease. It was now 18 months since we started the hospice care.