Chicago, Illinois, United States (Winter 2018)
“Is that her partner in there with her?”
Ankita, a second-year resident, and I had just finished seeing a new patient, Marian. Marian’s detailed problem list had required an equally detailed visit, and Ankita had addressed her urgent issues: uncontrolled diabetes, cirrhosis, and stage 3 congestive heart failure. As a good family doctor, Ankita had still managed to get to the question of the man in the room.
“He’s her landlord,” Ankita said.
“Landlord?” I had guessed boyfriend, friend, brother. But landlord?
“She doesn’t have any family.”
Marian’s skinny, ill habitus and stranding gray hair aged her well past her fifty-nine years. Her landlord looked like a “regular” fifty-nine – paint-stained pants, work boots, flecks of dark hair under the white.
I reflected that none of my landlords would have taken me to the doctor. Ankita said her landlord was a faceless corporation. Yet Marian and her landlord came in regularly – in addition to her other health conditions, she had wounds that would not heal, lung disease from years of smoking, though she had quit some years before, and atrial fibrillation.
It was hard to tell whether she took our advice or not. Did she take her meds, weigh herself daily, know what she ate? She was vague, though she endorsed a predilection for diet Pepsi. There was a lot in her way. Marian could not always afford her medications. She got by with social security disability, but her clothes were never new, and she often was not dressed right for the weather. I worried about her.
“Who helps you at home?” I asked during one of my attending pop-ins.
“I get along,” Marian said.
“If you needed help, who would you call?” I pushed.
“My son. Or Ron.”
The landlord again. The son was a new one. Marian’s son lived with her, it turned out. She called him misunderstood.
Marian got slowly sicker over the first year we cared for her, in spite of some wins. Her diabetes control improved a little. Her wounds healed, which felt like magic to all of us. But her heart failure worsened and she had a defibrillator placed. She had trouble getting onto the exam table. She used a wheelchair to come in from the parking lot. Her landlord used to be her ride. Now he stayed for the entire visit.
“When do you see the cardiologist?” I asked at the end of one visit. Marian pulled a thick, rubbed-banded stack of appointment cards from her purse and began thumbing through them. Some dated to 2011. Ron caught my eye and mouthed “September 25th,” but we watched Marian sort the cards till she found the one with the right doctor.
Ankita called me one morning to say that Marian had been admitted for high blood sugar and heart failure. We met in her hospital room.
“I got evicted,” Marian said, “I put my meds in a box that said DO NOT LOSE but then I lost it.”
Evicted? I thought. Evicted?! By the landlord who drives you to appointments and keeps your calendar for you?
“Marian,” I said instead, “where will you go when you’re ready for discharge?”
“I’m going to stay with Ron for a few days.”
Marian explained. Her son had been violent and unpredictable. He was on the lease, and in order to get him out, Ron had to evict them both.
“It’s okay,” she said, “Ron did what he had to do. My son’s not a bad person, he’s just troubled right now. My other son—” Other son? She had another son?—“has been more trouble lately. He’s been locked up for a while.”
Ron came by to pick her up at discharge. She rented another property from him. He brought her in monthly.
“How are your kids?” I asked at one visit.
“They’re okay,” Marian said. “Still having trouble with some stuff.” Ron rolled his eyes and mimed handcuffs. “But you know. They’re family. Whatever they’re mixed up with they can still have dinner with their mom.”
We all nodded, even Ron, who put the imaginary handcuffs away.
“She takes in strays,” he said. “It’s who she is.”
Marian made choices that made all of us nervous. When a chest CT found a nodule, she declined follow up. She did not want to know, even if it could be harmless, she said. Ron never questioned her decisions, medical or filial. He just kept bringing her in, helping her up, and escorting her home.
We needed him more as she got sicker. Ankita graduated from residency and Kinsley assumed her care. By the time he came on the case, Marian struggled to keep out of the hospital. The combinations of meds we used to keep the fluid off her abdomen and legs were too strong to maintain her circulation. She came in frequently for heart failure or low blood pressure, sometimes both.
“An update on Marian,” Kinsley said one day.
Marian’s son and daughter – daughter?! She has a daughter? I thought – had been arguing at Marian’s house. The argument escalated, got physical. Frail, ill Marian tried to separate them, got knocked out. She had been admitted to the closest hospital and consented to workup of the pulmonary nodule. Nodules. Mass.
Stage 4 lung cancer.
Marian took the diagnosis like another course of antibiotics, swallowing it with few apparent adverse effects. She felt the same. “Everyone has to die from something.”
Ron, on the other hand, was in tears telling us the story.
“I’m just worried about her.”
I was worried too. I patted his shoulder.
“You’re doing a great job taking care of her,” I said.
“Her daughter moved in with her to help out.”
By Marian’s next admission, four days later, her daughter had moved out again.
“It’s okay,” Marian said. “She drinks.”
I could not safely discharge Marian to an empty house, and she refused to go to a skilled nursing facility, so we discharged her to Ron’s house. Of course.
Ten days later a Rapid Response code interrupted inpatient teaching rounds. Kinsley called.
“That Rapid was Marian. She fell in the parking lot. She’s in the ED.”
“She can’t walk anymore,” Ron told me, very quietly, from the corner of the exam room.
“How long?” I asked.
“Three days. She’s been vomiting and hasn’t eaten either.”
“Can she still drink?”
“Lots of diet Pepsi,” Marian said.
We laughed, but Ron’s face twitched and he produced a sandwich bag with six large fuzzy pills.
“She threw these up yesterday.”
Ah, metformin. Well, diabetes was the least of my worries. But he had extricated them from her vomit and brought them in?
“Ron, you’re a wonder,” I said.
Within two days Marian had become unstable.
“I’m done,” she said. “Time to stop. Hospice.”
I talked to Marian. I talked to her sister – her sister?! – to confirm the plan for comfort care.
“Is Ron there? Can you call Ron?” her sister asked.
Kinsley called Ron.
“Is she okay? I’m coming right now.”
I imagined him driving, worried, and seeing her so much worse than she had been that morning. She was relaxed and comfortable with meds, but her skin was mottled and her respirations fast. She was not arousable or talking. I settled into the chair in Marian’s room and waited for Ron. He had been there for Marian for so many years. I could spare a few minutes for him.
He came in slowly. I got up to give him the good chair and could smell fresh paint on his work clothes and feel the cold still on him. He had hurried to get here, and now he did not want to be here. The door opened wide enough for him to see Marian, and he sobbed and apologized for it. I offered him a box of tiny hospital tissue. He took one and I tossed him the entire box.
“She took care of my dad when he was dying. She rented from me, but when he was sick she came over and helped. Just who she is.”
“Don’t you think you’ve helped her?”
“It’s not the same,” he said. I could not believe it.
Marian died the next night, peacefully. Ron was there, and so was all the family I never knew she had.
A couple of days later, I composed a sympathy card for Ron at the nurse’s station. I would miss taking care of Marian. I would miss seeing her and Ron. I hoped he was doing okay. Before I got a word down, my pager rang and I stepped to the hallway to take the call.
Ron ambled down the corridor, swinging two 2-liter bottles of diet Pepsi.
“Thank you for everything. For you, and Dr. Kinsley.”
He was thanking me? How could he even think about someone else at a time like this?
Kinsley joined us, and we talked in the hallway, leisurely. Watching Ron help Marian helped me. Marian gave and she received. She took in the strays. She put kindness into the world, giving to people who were not always grateful. She loved her family, but they could not be what she needed. Ron’s kindness to Marian came straight from Marian’s kindness. He was not paying her back because he owed her. He helped because she created good in him. I needed this example. I needed to see and remember all this kindness. We see a lot of meanness in medicine, and Ron’s selflessness reassured me. I did not want to let him go.
Finally we were out of things to say, so we hugged, and he left. Kinsley and I stood in the hall with our bottles of diet Pepsi.
“Let’s try not to forget this,” I said. He nodded.
KATE ROWLAND is a family physician in academic practice with the family medicine residency at Rush Copley in Aurora, Illinois. She also serves as the associate clerkship director for the primary care clerkship at Rush Medical College in Chicago and is an associate medical editor for the American Academy of Family Physician’s FP Essentials. She speaks on a variety of medical topics at state and national meetings.