Mrs. M’s refusal

Ladan Golestaneh
Bronx, New York City, NY (Winter 2018)

 

My role as a physician includes foregoing a prescriptive approach to some patients in favor of a supportive one. Yielding to a belief system that does not fit the structure of my many years of training feels like a personal failure. But sometimes I know I have to listen and wait for my patient. I learned this lesson over many years of offering aggressive, life altering, burdensome treatments and getting repeatedly rejected.

Mrs. M personifies the delicate balance of magnanimous and effusive personal charm with the impenetrable and stark set of decisions that my job urges me to influence, but against which I will not succeed. Her austerity and her strict adherence to her choices give me very little room as her doctor. I have to reconcile my duty to respect her right to refuse my treatment with knowledge of what can happen if she does, while she is more preoccupied with managing daily life functions and making sure her physical reserves can handle them through extreme discomfort.

She visits me every three months during my nephrology office hours. She never misses an appointment and is never ever late. Her good-natured humor and mastery of daily pleasantries stand in stark contrast to her life circumstances and her complex clinical problems. She has a complicated medical history that includes HIV, with periods of very high viral loads and low CD4 counts, many years of diabetes, hypertension, and severely advanced kidney disease. She is never accompanied by family or aides and she lives alone in a low income housing unit in the South Bronx.

“If you don’t say the word dialysis to me, then me and you will get along fine,” she had said to me early on in our relationship.

I see her name on my clinic schedule and I am delighted by it. She kneels over her walker and shuffles down the hall towards my exam room. She has perfectly applied makeup and pomegranate colored lips, full and smooth. She is wearing a daringly fitted dress with patent leather shoes, a turquoise shawl around her neck, a ridiculous floppy matching turquoise bow in her jheri-curled hair, sky blue earrings, and silver bangles on her right wrist. They jangle each time she pushes the walker forward. She is strikingly beautiful. I hear her telling the gentle young technician, Michael, who has taken her vitals and is leading her to my office that he “better watch out or I’m gonna call your wife in Africa, all them girls flirting with you and you liking it, don’t you think you got one up on me.”

He looks embarrassed but humored by her straightforward maternal manner and her twang.

She sits down at the chair next to my computer, rolls the walker to one side, leans her head back and gives out a satisfied laugh as if she is alone in the room. She then looks at me directly in the eyes.

“How you doin’ baby?” she asks, as her bow dances on her head.

She tells me she takes her medications all at once after she dissolves them in her cup of coffee each morning. It is understood that this is the only way she will take them. She appreciates that the dissolutions of some her pills in the coffee renders them inactive and that her medication schedule is more complicated than “all at once in the morning.” She does not care.

“You so silly worrying about me. Look at you, all serious. It don’t matter, baby, but I appreciate it, I really do.”

I ask about her family. I once reached out to her daughter who was engaged and intelligent. She had no influence on the pill-ridden coffee cup in the mornings, though. Mrs. M rules her domain with a confidence that suggests nothing can coax her into doing things a different way. The kind of confidence that comes with having endured pain. Searing, suffocating, pernicious pain, I imagine. She contracted HIV from a husband who died of a drug overdose. She had three children; but one son had been murdered when he was twenty-two. I tried to broach the subject with her as a way of getting through to her.

“It’s in the past,” she said.

A few minutes passed in silence and she then started moving her upper body to the beat in her head.

“I like to dance, ooooh you should have seen me when I was younger, we would go out with my girlfriends, it was beautiful. Just like you, baby, you beautiful,” as she continued to gesticulate. “You like to dance?”

My encounters with her have become an informal dalliance between old friends. I cannot convince her to do what is needed for her health, but I am the person she visits. I give a quarterly schedule to leave the house, a listening ear to tell about her plans at the senior center that day, someone to whom she can give advice on how not to forget to love. I once told her about my son and his struggles with pre-teen social pressures. She listened and told me to be patient with him and show him that I love him. She asked me about him at every follow-up appointment after that. “And tell his father to deal with his hormonal problems,” she laughed.

I wonder if I am doing her a service by repeating my instructions about taking her blood pressure medications in divided doses and eating less salt. I reiterate that because she is such a young seventy-eight-year-old who has her wits about her, she should really consider dialysis as a way to prolong her life. She remains intransigent.

“I don’t want to talk about that,” she sternly repeats.

She reaches into her walker and pulls out a small scented candle, rosemary and sea salt flavor, packaged in a plastic crystal case. “Even though I don’t listen to a word you say, you know I love you,” she says as she hands it to me. I chuckle and appreciate the gesture wholeheartedly. “I happen to be obsessed with scented candles.”

She nods. “I know you, and I appreciate you caring about me.”

I ask her to shuffle to the exam table and with painstaking attention she makes her way to the stool I am holding for her. She clumsily climbs it, holding the side of the exam table with her red nail polish and knuckles that show cracks at the edge of wrinkles. I go through a few contrived and formal motions. I listen to her back, take a blood pressure which I do not record and would like to forget about. I examine the swelling in her legs. Then I realize there is nothing I can do. But I am not frustrated. She knows the exam is over, she knows the routine. She starts to grab the stool and the side of the exam table.

“Mrs. M, why do you come see me if you don’t want to follow anything I say?” I ask her.

She responds without any hesitation: “Because I love you and you love me.” She then gives me her pomegranate lipstick smile and calls Michael the tech to come get her and escort her out.

“I have a party at the center today, I don’t want to be late.” She gets to her walker and begins a slow exit out the door.

She hesitates and looks around to me: “Take care of that baby boy, and I will see you in three months.”

 


 

LADAN GOLESTANEH, MD, MS, is an associate professor of medicine in the renal division at Montefiore Medical Center. She served as medical director of Montefiore’s inpatient dialysis unit, a large outpatient dialysis unit, and medical director of the home program unit in the Bronx. Dr. Golestaneh is interested in care delivery models for End-Stage Renal Disease patients, a project on which she collaborates with the Montefiore CMO.

 

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