A History of the Present Illness (24 page)

Returning to work after such jaunts, I often pause before that internship photograph hanging behind my office desk. I notice not just the clothing and facial expressions but our positions and postures on the steps as well: Josette, shy and awkward, laying claim to me with her hip; Lamar flexing his muscles; Nam pretending he isn't taking seriously the business of being a doctor; and Sumita and Althea positioned both close enough to each other and far enough apart to heighten the charge between them. I stand front and center, a place I fought for, while Perla stands off to one side, at the edge of the frame. It's funny, but I've only just recently realized that if we have changed over the years, it's only in the most superficial of ways, and also that most of us have ended up right where we wanted to be that very first day.

Hattie Robinson was a jazz singer in the 1930s, the only female black labor leader in Northern California in the '50s, and a regular in the Letters to the Editor section of the
San Francisco Chronicle
for decades. At ninety-six, she began nude painting—not portraiture of disrobed others, but art made by her in a totally naked state and in the absence of most other social conventions. I met her the following summer, called to her home by a social worker for Adult Protective Services.

I'd recently given up my clinic and academic responsibilities as the family medicine program director at San Francisco General, but unwilling to fully succumb to retirement, I had begun spending my mornings making house calls to patients in homes and apartments across the city. My wife, Carly, a former advertising executive, suggested that I call my new venture From Projects to Penthouses. Throughout the twenty years of what had been for both of us a midlife second marriage, Carly had expressed both pride and fascinated repulsion at how I sometimes spent my days. She felt that a catchy, accurate, but
possibly misleading title might be my only hope of building a viable practice.

As it turned out, no marketing was necessary. More so than most urban centers, San Francisco's world-famous hills have produced a city replete with ancient and otherwise disabled people rendered invisible by their inability to go out. Referrals poured in by word of mouth alone, and within months of starting the practice, I had to increase my work hours to keep pace with demand; I couldn't abide the very real possibility that the time a potential client spent on my waiting list might exceed his or her life expectancy. Carly noted that most retirements looked significantly different from mine, but I could see no better way to spend my time than to offer patients good care and a dignified death at home.

The social worker told me that Hattie had been seen in the emergency department several times in the space of a month, each time for something silly: an ingrown nail, a bruise not black and fresh but with a halo of lighter brown, a cut so small no sutures were needed. Each time, her daughter brought her in, dropped her off, and disappeared. Each time, the daughter was slow to return when the hospital called to say there was no reason to keep her mother.

They lived in a worn but still handsome Victorian in the Lower Haight, a neighborhood of drug addicts, pierced and tattooed young professionals, and people like Hattie, who predated not only the current counterculture fashionistas but also their flower child predecessors. In the broad, high-ceilinged foyer, I was greeted by a huge Benin plaque and African masks elaborately decorated with feathers and what looked like real human hair. Framed reprints of book covers lined the long, wood-paneled hallway in pairs:
Cane
and
Their Eyes Were Watching God
,
Another Country
and
Native Son
,
Black Fire
and
Letter from Birmingham City Jail
,
Beloved
and
The Color Purple
. Just before we turned into the bedroom, a collage of the numbers 1, 9, and 3 provided the single false note in an otherwise impressive decor. Nineteen thirty-one, explained Hattie's daughter, Patricia, was the year of her parents' marriage. They lived in Harlem then, but came to San Francisco after the war.

Hattie stood in one corner of her room, naked and painting as promised. She sang an aria of sorts and turned circles on a tired patch of carpet. When at last I got her attention, she couldn't tell me who she was or where, though she remembered how to scream and scratch and kick, all of which she did when I examined her, careful to steer clear of the urine-soaked rug and elaborate swirls of stool on the walls and bed. (Later, Carly cringed at these graphic details when I told her about my new patient. “Oh God,” she said. “I had no idea it could get that bad.”)

When I finished my evaluation, Patricia brought two chairs in from the kitchen and said, “Momma always did tell me she planned to live forever, but no way did either of us ever imagine something like this.”

“What did you imagine?” I asked.

Patricia glanced up at me, surprised. “I suppose we thought she'd be like my daddy. He took sixteen pills a day and needed a wheelchair his last two years, but he was still himself, right up to the end.” She pointed at her mother's vanity, where a halo of photographs encircled the mirror: Hattie and a bald man about my age waving from a car beside Willie Brown; Hattie speaking through a bullhorn outside a factory while the same man—younger and with a full head of hair—stood to one side holding a picket sign; Hattie posing in front of the Victorian at a time when the paint looked fresh and new,
while the man—middle-aged but sporty-looking despite the cane in his left hand—grinned up at her.

“So now you're wondering how best to take care of your mother?” I asked.

Patricia nodded and looked across the room. Hattie sat on the sofa rapidly turning the curled pages of an old magazine.

Seeing Patricia's profile, I realized she too was quite old, early seventies at least. (“
Quite old
,” Carly said that evening with a laugh. “Should I remind you of your own birth date?”)

“Sometimes,” I said to Patricia, “we can make an educated guess about what a person would have wanted based on their choices when they could make their own decisions. How did your mother handle her health? Did she go for regular checkups or just see a doctor when she got sick?”

Patricia threw back her head and hooted. “Mother never did care for doctors, said they were always thinking they knew best and how could some stranger who saw you once or twice a year know what was best?” She smiled. “No offense, Dr. Westphall.”

The tone of her apology concerned me. It was the overly accommodating tone of a caregiver pretending that she wasn't exhausted and angry and utterly convinced that there wasn't anything that could be done to improve her situation.

“But your mother did see someone occasionally?”

“Not unless I dragged her. And that never did any good anyhow, because she'd just refuse the mammogram or Pap smear or whatever else they wanted to give her.”

That morning, I spent more time with daughter than with mother. We talked of Hattie's weight loss and her incontinence and how hard she fought when Patricia tried to clean her up. And then we discussed what could be done and what couldn't, what should be done and what shouldn't. When I proposed
a fairly conservative approach to Hattie's care, Patricia said, “Whatever you think, doctor. You're the expert, not me.”

“But you're the one who's with her twenty-four seven.”

“Ain't that the truth.” She went to the window. She had a hitch in her step I hadn't noticed earlier, and I wondered what sort of medical problems she had of her own. Just as I was about to break the silence, she turned with her hand outstretched. “Thank you for coming, Dr. Westphall. You've been a big help already. Mother and I will look forward to seeing you again.”

As I was leaving, Hattie stood, paintbrush in hand, and said, “Let's tulip the lampshade while climbing the cradle.” I made the hospice referral from my car before pulling away from the house. “No rush,” I told the intake nurse. “This could take months.”

Three days later, I received a message from Patricia that Hattie was being admitted to the hospital. She had a fever and didn't seem able to move her left side. When they'd put a catheter into her bladder, pus drooled into the bag.

“Comfort care,” I told the residents.
Comfort care,
I wrote in my note.

That night Hattie got three IVs, five medications, a spinal tap, a CAT scan, and a Posey vest restraint. Together, teams of neurologists and radiologists localized the lesion in her brain. She'd had a massive stroke, the result of a clot in the artery that controlled her right side as well as her ability to speak and swallow. When I inquired why my orders had been ignored, the intern said there was no advance directive and her attending didn't want to withhold care just because the patient was old.

When I called the attending, he said the daughter had told him to do what he thought best.

“But this isn't what Hattie wants,” I argued.

“There's no advance directive,” he said. “You can't know what she wants.” It was a point I had to concede.

I phoned the old Victorian five times that morning and continued calling over the following several days but never reached Patricia. I assumed she was at the hospital or that she'd taken advantage of her mother's absence to run some errands or go out with her friends. (Carly, the cynic, suggested that maybe Patricia had caller ID and no interest in speaking to me.)

On her fifth day in the hospital, Hattie developed black heels and a chasm around her tailbone. A white cotton cuff looped around her left wrist, which was fixed to the metal bed frame by two long straps tied with bulky knots. Her right arm lay flaccid on the sheet, the hand already beginning to curl in on itself. She couldn't speak, but she looked my way when I spoke to her in the singsong voice I generally reserve for pets and my youngest grandchildren. Her left arm bucked against its tether, and a feeding tube hung from her right nostril, its other end disappearing down the back of her throat. Every few seconds, the machine beside her bed clicked, and a drop of liquid food, pale and pasty, fell into the clear plastic tubing and made its slow way to her stomach. (I had a similar tube once myself, in medical school; they made us insert them into one another in hopes of teaching both proper technique and appropriate restraint. I gagged repeatedly, the plastic rod an assault on the natural order of what does and does not belong in the human body. I tried to be strong but lasted only seconds. Worse, although I'd skipped breakfast as instructed, after my lab partner pulled out the tube, I heaved into a trash can. And I wasn't the only one. That night, I told Carly that I'd have to be tied down or drugged to let anyone do that to me again.)

At the end of the week, the intern caring for Hattie left a message on my voice mail. “Ms. Robinson's rallying,” she said. “Her numbers look good.” Code words for
I want her off my service
.

We've all spoken similar words.

I called back, and the intern said they'd filled out the paperwork for a local nursing home. I told her I only did house calls, but I'd be happy to continue caring for Hattie if her daughter wanted to try taking care of her at home.

I didn't hear from the intern again and so went on with my life and work, as one must. (“How can you?” Carly sometimes asks lately. To which I answer, “How can I not?” I want to help, and often I do, but my role comes with inherent limitations. What's more, I see only a sliver of each family's story, so it's impossible to judge decisions that might equally be considered selfish or the single available route to legitimate salvation.)

“It's disgusting,” Carly declared when I told her what had happened to Hattie. We'd driven out to the Mission District to try the latest Nuevo Latino sensation, a Peruvian restaurant that blended traditional flavors and California cuisine.

“I think you mean shameful.”

Carly speared a hunk of halibut from the bowl of ceviche between us and waved it in the air as she spoke. “No, I mean disgusting. What's shameful is your behavior. Can't you do something for the poor woman? Isn't that your duty, if not as a doctor, then at least as a decent human being?”

I spotted a small curl of green chili in the ceviche and avoided it. Spicy foods had begun giving me indigestion.

“I couldn't reach the daughter. I don't go to nursing homes any more than I go to San Jose or Afghanistan. What exactly do you think I should be doing?”

Carly raised her eyebrows and lowered her voice. The restaurant had received a bomb in the noise-rating category, so I had to read her lips to understand her.

“
Help
her. And stop being obnoxious; you know perfectly well what I mean. According to her daughter, her wishes were clear enough.”

I put down my fork. Carly, her hair pulled sleekly back into a perfect bun to show off the dangling diamond earrings I'd bought for her birthday, cut into a small fish laid upon a bed of wilted greens and enormous white corn kernels. I put my hand over hers.

“What if I came home one night and said I'd strangled Hattie? Put a pillow over her head? Injected—”

Carly shook off my hand. “Stop it! I didn't mean that. You know I didn't mean that.”

“Is there a difference?”

“There has to be.”

She abandoned the serving spoon and fork. Beside us, a young foursome argued the pros and cons of public and private education.

Carly folded and refolded her napkin. I lifted fish and accoutrements first onto her plate, then onto my own. The restaurant deserved its three stars; the fish melted in my mouth.

“What if it were me?” Carly asked. “If I were like Hattie is? Would you help me?”

For the past couple of years, Carly had had trouble coming up with names of acquaintances and movies we'd seen, little slips that might have been part of normal aging. At first, like many of our friends, we'd made jokes about senior moments. Then my daughter had told me that Carly called our grandson twice the same morning to sing “Happy Birthday,” and a short
while later she'd turned the wrong way up a one-way street and didn't notice until a car came toward her head-on.