The fallen leaf
Psychiatry and Consultation for the Social Security Administration, Baltimore, Maryland, United States
Photography by Orbmiser
As a consulting psychiatrist, my job is fairly straightforward. Often questions involve determining the appropriate DSM-IV diagnosis or medication to calm an agitated patient. However, this day I was asked to see a 42-year-old woman, and the only reason given for the consult was, “the patient is dying from end-stage breast cancer.”
I was startled. Never before had I received such a consult. Asking the referring physician for more information, I was left even more perplexed when he simply responded, “It would be a good idea for you to see her.” Now aware that the referring physician was uncomfortable dealing with a dying young person, I knew it would be fruitless to pursue more specifics.
I briefly remembered reading that in Europe, some Christians have a ritual, called “Clinic,” in which a priest holds a bedside vigil for a dying person, watching and praying as the inevitable takes its course. Without such rituals at my disposal as a psychiatrist, what was expected of me? Trusting my instincts, I felt something would guide me once I met the patient. I had such unfounded confidence in retrospect.
As I walked into the room, I saw a young woman, startlingly healthy in appearance and quite beautiful. I thought I had mistaken the room number or the patient, but I was in the right place. She seemed to notice my hesitation, and in a turn of patient-doctor dynamics, she made me comfortable at once.
“You are Dr. Kang, right?”
“Yes. Dr. Carter asked me to visit with you.”
Calmly, she explained everything I needed to know. “I asked Dr. Carter for a psychiatrist. As you know, I am dying, and I just don’t want to fall apart in front of my family.” She went on to tell me about her wonderful husband and three young children, the youngest only six years old. “If you could watch me, I will be all right, I imagine. I have had a life with no regrets. I cannot ask for anything more, except that if they see me break down, it will hurt them deeply. I can’t have them hurt like that.”
I was out of my element. The usual ritual of taking a detailed history was unnecessary; she told me so much in only a few words. As with many psychiatric illnesses, diagnosis and treatment can be quite simple. And yet, I felt rather helpless. My armamentaria of treatments were completely useless in this situation. Her confidence was so strong. Mine had disappeared.
Confounded, I sputtered, “Is there something special I could do to help you?”
Settling back into her pillow, she said again with superb confidence, “I know you are a good doctor. You just watch me, and stand by me, and I will be all right.” She looked at me and asked, like a child, “Is there such a thing as a beautiful death, doctor?” Without waiting for an answer, she asked for my help in gathering her family into the hospital for a final visit. It was the least I could do.
The next day, she greeted me with a bright smile and thanked me for arranging the visit with all her children the night before. She repeated what her young daughter said, over and over again: “Mom, I will love you forever.” She pondered, “I wonder if she understands what forever means. I wonder if she knows anything about death. But they must know something—they put so much effort into comforting me. They are such good children.” She told me how the two older boys, ages 8 and 10, tried in vain to control their tears. She knew their father had tried to coach them not to cry, so as not to upset their mom.
“But I knew them. I hugged them, one on each side. They just buried their little faces in my lap and sobbed. I winked at my husband to let him know I was okay. I could tell he was trying to keep his smile up. He is such a good man. Oh, how blessed I am!” After a long sigh, she continued. “He told me, ‘Don’t worry about the kids. I will raise them so that you’ll be proud of them, watching from above.’ He told me he would love me forever, and he said goodbye.”
After a while, I left her room. But no sooner had I walked down the corridor from her room when a panicked nurse ran after me. She said the patient was hallucinating. I rushed back, knowing that death could be terribly close. For a moment, I was distracted by the swiftness of her clinical change; then I remembered my promise.
As I came to the bed, I held her hand, and she clasped it in turn. She was murmuring something. I bent my ear down.
“Thank you, doctor. Goodbye, doctor.” Her voice was small but clear, like the water of flowing stream. Like the stream, the waters had finally found their destination.
In the moments after her death, I ignored the busy morning rounds and chatting nurses and found my way outside to the back of the hospital. It was autumn. A beautiful, bright yellow leaf gently brushed my shoulder and slipped to the ground. I didn’t wipe away my tears as I walked in circles. I murmured, “Father, please receive this beautiful soul, won’t you?”
Later, I didn’t know what to write on my chart. “Grace under the overwhelming inevitability of death” was something that needed no diagnosis, no pill. I had only a hand to offer, but it turned out to be all that was needed.
CHANG-WUK KANG, MD, attended medical school at Seoul National University, Korea, and now has a private practice of Psychiatry and Consultation for the Social Security Administration. Previously, Dr. Kang was the director of Psychiatry at St. Agnes Hospital, Baltimore, Maryland. His specialty was liaison-consultation psychiatry.