Making Rounds and Oscar (2010) (11 page)

CHAPTER FOURTEEN

"Dogs have owners. Cats have staff."

UNKNOWN

AS AN EARLY WARNING SYSTEM, OSCAR'S AVERAGE WAS
proving to be uncanny. "What do you think would happen if we had two patients who were dying at the same time?" I asked Mary one afternoon not long after Mrs. Matos had passed away.

"That actually happened!" she said. We were sitting in her office behind the front desk and the third floor was very quiet. "They were both going; it was hard to say who was going to die first. But one of them was very comfortable; you remember your patient, Larry Scheer?"

I nodded as Mary continued.

"At any rate, Larry was a hospice patient and he was doing okay. But this other gentleman, he was all the way over on the other side of the ward and having a real tough time of it. He had great trouble breathing and couldn't get comfortable. That's who Oscar chose to be with!"

"As if he could tell he was having the more difficult time."

Mary nodded. "His poor wife was there, watching all of this unfold. I remember walking down the hallway to see her, thinking how terrible it must be for her, but she was accepting of the situation. I asked her if there was anything I could do and she told me that Oscar was there for her husband and that they both would be okay."

"It sounds like Oscar was distracting her from a pretty miserable scene."

Mary smiled at the memory. "I guess," she said. "At one point, I think she even broke out her camera to take a picture of Oscar." The idea of a positive memory in the midst of such a bleak scene was strangely comforting.

I looked down the hall, searching for the cat in question. Maya was curled up on a chair behind the desk, but no Oscar.

"Speaking of," I said, "where is he?"

"He was with one of your colleagues' patients last night and I guess he's just wiped out. He disappeared somewhere. It's like he hibernates."

"Does he eat when he's on the job?"

"Sometimes...but it's not like he dawdles. He'll slip out for two minutes, grab some kibble, and then he's back at the patient's side. It's like he's literally on a vigil."

I was imagining Oscar sleeping somewhere, perhaps in a closet or under a bed. "What do you think it's about, Mary?" I asked. "Why does he do what he does?"

"I thought that's what you were trying to find out by talking to the families."

"Partly. But as they say, peel an onion...I'm curious: What's your take?"

She sat back in her chair and mused for a moment. "Well, you know, Oscar is my baby. He bonded to me right away. I would give him his ice water every morning."

"Man, these cats are spoiled! Nobody brings me ice water."

Mary smiled but then turned serious. "If you've ever had a pet, you know that when someone in your family is in trouble, the pet will usually go and stay with them."

I thought back on Jolly, the black miniature poodle that kept me company when I was sick as a child. "True," I said. "But that's different. My dog was part of our family."

"Well, what do you think this is?" Mary said. "This is Oscar's home. He has forty-one family members and when one of them is in trouble, he goes and stays with them."

I was quiet for a minute, thinking of the one cat that seemed to care for the forty-one residents on this floor. No wonder he was exhausted.

"So, who else are you going to talk to?" Mary asked, changing the subject.

"I don't know. I guess there are still a number of people on my list to interview. Based on your story, I suppose Mrs. Scheer should be on the list. And I still have to get in touch with Jack McCullough..."

The call bell rang at the front desk, interrupting us mid-conversation. Mary leaned over and hit the button.

"Can I help you?"

Frank Rubenstein's unmistakable voice answered.

"Mary, I need you. Can you look at my wife?"

Our conversation had come to an end.

"I guess it's time to go back to work," she announced as she disappeared down the hall.

I grabbed Ruth Rubenstein's chart off the rack. Ruth had recently been readmitted after a weeklong hospital stay for a bout with pneumonia.

Her infection had quickly improved in the hospital, but the change in environments left her confused and delirious. She stopped eating and needed powerful medications to help keep her calm. Eventually, a one-to-one aide was required just to keep Ruth from getting out of bed and falling in the middle of the night.

As I reviewed Ruth's hospital records, I became aware of a presence. I was not alone. Oscar had materialized as if from nowhere, and was sitting on the ground next to me giving me the fish eye.

"What?" I said. "Am I in your spot again?"

He meowed--softly at first, but more forcefully each time.

"You're in his way," Mary announced with a chuckle as she returned from Frank's room. She pointed down to the water bowl beneath the desk. "Your feet are in his way."

"My apologies, Your Highness," I said standing up. Eyeing me suspiciously, Oscar waited until I had moved to the other side of the desk before tiptoeing in to have a drink.

"Would you look at that?" I cried.

"It's his desk, David; just be happy that he lets you work here from time to time." It was becoming her new mantra. This was Oscar's world.

"Frank wants to see you," Mary said, bringing me back to reality. I looked at her for more explanation.

"Ruth's been too confused to eat anything since she came back. We've tried to sit with her--you know, to get her to take something--but she won't take a bite. He's been out here at least a half dozen times this morning already asking how he can get her to eat. The last time I told him that she would eat when she's
ready
to eat. I even tried to reassure him by saying that she was still receiving IV fluids and that was helping."

"How did he react to that?"

"He nearly bit my head off! Then he walked off muttering that I wanted his wife to die."

It's never easy for family members to watch their loved ones refuse to eat. Eating is essential to life, and families at the nursing home often use it as a barometer for how someone is doing, never mind the fact that everybody's appetite varies from time to time.

"So, what did he want just now?" I asked.

"Same thing. He wanted to know if I could get her to eat her lunch. She didn't touch a thing."

On my way toward Ruth's room I passed Louise, asleep in a hallway chair, her walker parked carefully by her side. As usual, she was meticulously groomed: Her white hair had been cut and delicately curled. Her off-white blouse was paired with a skirt that modestly covered her knees. She looked peaceful, as if she had fallen asleep during a church service with thoughts of salvation in her head. Not for the first time I wondered, What was she dreaming of?

It's a big question. Do people with dementia dream as they once did, or are their dreams disordered and fretful, a by-product of their disease? Do their dreams offer a respite from the confusion of their waking state, or do they contribute to it? It's something I've wondered a lot about. After all, many scientists have suggested that dreaming is critical to learning--it's the brain's chance to reorganize itself, to process memories, and perhaps store them away so they can be accessed later. So, what does that mean for the patient with memory impairment?

And what about the medications? In early dementia, patients are often treated with Alzheimer's drugs that increase acetylcholine levels in the brain, which can lead to profound and sometimes disturbing dreams. Yet in later stages of the disease, you hear less and less about patients' dreams. Perhaps they cease to be as important or memorable. Perhaps they lose the recollection of even those. Still, as I watched Louise softly snoring, I hoped she was at peace in her dream world, and that some of the memories she had lost access to in her waking life were restored to her in sleep.

Was she dreaming about her husband, the handsome flyer in his World War II uniform forever ready to launch or just returned from some sortie? I tried to imagine Louise's life then, what it must have been like to love someone who had gone off to fight--the loneliness and the fear. Maybe she was dreaming of that, or of his return from the war. Perhaps she was reliving her unbridled joy at seeing him alive and safe, a young family reunited, ready to resume the lives that history interrupted. It was heartbreaking even to consider it.

There are some memories that should never be lost. Are they found again in dreams?

RUTH WAS LYING IN BED
, her eyes shut. From the look of it though, she didn't appear to be sleeping as she writhed around fitfully. Unlike Louise outside in the hallway, there were no pleasant dreams here, I was quite confident about that. I knocked on the inside of the door to announce my arrival. My knocking startled Ruth, and she opened her eyes. Frank, seemingly dozing himself, jumped to his feet and looked around.

"Oh! Dr. Dosa, I'm so glad you're here." I could hear the worry in his voice.

"How is she doing?" I asked as I walked to Ruth's bedside.

"Not good, Doctor. She's really not herself. I'm not even sure why they sent her out of the hospital. She's still very confused."

I pulled up a chair and sat down next to Frank.

"She's delirious, Mr. Rubenstein."

"What does that mean? Is her pneumonia still there?"

"No, that's been treated. But sometimes, when older people get sick, their infections can cause them to become increasingly confused. 'Delirium' is the term we use to describe that confusion. It's a change in the way patients pay attention and focus. It's why Ruth is so agitated right now."

He looked at me with a blank stare. I tried another tack.

"Her condition is similar to that of a small child who might see spiders on the wall if they have a high fever. Older people, particularly when they have memory problems like your wife, are prone to becoming confused when they have even innocent infections that wouldn't have affected them before. We call this delirium and it can persist even after the infection goes away."

"Will she get better?"

"I expect that she will get better over time, but it might take several days or even weeks."

"But she's not eating, Doctor!"

Ruth moaned from her bed. I took this as an opportunity to examine her. Sitting beside her on the bed, I placed my stethoscope on her chest. She resisted immediately, lifting up the upper half of her body while swatting at me forcefully with her hand. Frank jumped up from his chair and got on his knees next to his wife's bed. He took her hand and held it tight to his own chest. His face was filled with concern.

"The doctor's here, Ruth," he said. His tone was beseeching. "He's here to make you feel better."

I felt bad for Frank. There was actually little I could do to make her feel better other than treating her baseline infection. Despite all of the modern miracles in medicine, time alone would fix Ruth--as much as she could be fixed.

Still, her husband's reassuring voice seemed to calm her and she settled back down onto the bed. I continued my exam.

"What about the eating, Doctor? How do I get her to eat?"

"You may not be able to get her to eat right now, Frank."

"But if she doesn't eat, she's going to die!" He glared at me in frustration. "Do you want her to die?"

"No one wants her to die, Frank."

"How can she get better without nourishment?"

I sat down in the chair and measured my response.

"Frank, we are doing the best we can with feeding her given her current confusion. The nurses and the aides are trying their best. They sit with her at every meal and patiently try to feed her. I'm sure a little of it is getting in. She's also getting hydration through her IV fluids, which are providing some sustenance. When her delirium improves, I think she'll start to eat again."

"But we fixed her infection, Doctor."

"We did, but the resulting confusion takes time to improve." I felt as if I were saying the same things over and over.

"Well, if she's not going to eat, shouldn't we put in a feeding tube?"

Frank's frustration had changed to pleading.

"Frank, I don't think it would change the overall outcome. Besides, when your wife was still able to speak her mind she told me she didn't want a feeding tube to help her with her nutrition. Shouldn't we honor her wishes?"

Suddenly, I realized how thankful I was that the three of us had discussed this matter in the early days of Ruth's dementia, while she could still participate in conversations regarding her future. Of all the things I talk about with my patients and their families, the discussion about feeding tubes is perhaps the hardest. I have seen families literally ripped apart by the often agonizing decision of whether or not to insert a feeding tube into a dementia patient who has begun to lose weight. Part of what makes these conversations so hard is the common misconception that feeding tubes prolong life. In reality, there is really no place for feeding tubes in terminal dementia. Objectively, they have never been shown to increase a person's length of life or reduce the number of episodes of pneumonia. Feeding tubes are not without their side effects: They require a surgical procedure or endoscopy to insert them in the first place; they fall out easily, requiring ER visits simply to put them back in again; and they can get infected or become blocked.

There's another factor that makes conversations about feeding tubes difficult. Many people feel that not feeding patients is tantamount to cruel and unusual punishment. Unfortunately, loss of weight at the end of life is a natural byproduct of the body shutting down as it prepares itself for death. Patients at this stage of life do not perceive hunger or thirst the way someone who is healthy experiences it. But it's never easy to convince family members of this as their loved ones are fading away. It's infinitely easier when the patient has consciously weighed in on the matter at a more opportune time.

Frank looked at me with a guilty expression.

"You're right, Doctor. She did say that she didn't want a tube. She's got to eat, though. How can she get better if she doesn't eat?"