Anthony Papagiannis
Thessaloniki, Greece

It has been said that the impact of whatever happens to us owes 10% to the fact itself and 90% to our own response. Consequently, our happiness—or lack of it—under any circumstances is largely in our hands. This is quite obvious in the field of health and disease, as the following story shows.

The sensation of breathlessness—lack of air or difficulty in breathing—is one of the most troublesome symptoms one can experience, in its extreme form worse even than pain. Breathing is synonymous with life, and any impairment of this vital function, either real or perceived, is interpreted as a threat to our existence. However, the perception of breathlessness is subjective. This does not mean it is nonexistent or imaginary; it describes each person’s unique and individual experience of the same physiological phenomenon.

Over the years I have had many opportunities to observe this in respiratory medicine. Dyspnea is one of the main reasons people visit chest doctors, but the range of responses to this unpleasant and often disabling sensation is quite broad and does not correlate well with objective lung function measurements. It is not uncommon to see chronic respiratory patients complaining of severe breathlessness with reasonable lung function, while others with much lower lung capacity report much less discomfort, and consequently have a better life quality.

Whenever I am faced with complaints of dyspnea disproportionate to the measured lung function and other objective findings, I am reminded of Yianni. He was a seventy-year-old ex-PE instructor who had smoked most of his life and came to me with severe COPD. His lung function was 20% of predicted at best, and he was already using a portable oxygen cylinder to move around. This did not stop him from getting on the bus and riding a couple of miles to my office for checkups and prescriptions. I never heard him complain; a smile never left his face, and he was always ready to crack a joke, often at his own expense.

He had been under my care for several years when one day I got a call from his wife, who told me that he had been admitted with profound deterioration of his breathing. Intubation was required, the acute problem of infection was managed successfully, but he could not be weaned from mechanical ventilation, and a tracheostomy was performed. While he was in the hospital, he unexpectedly passed blood; a tumor was found in his colon, but his nonexistent respiratory reserves precluded any intervention. Eventually he was discharged on palliative measures alone, with a ventilator for continual use. When I visited him at home he greeted me with his habitual broad grin and formed with his lips a voiceless “I am quite well, thank you” while the ventilator kept inflating and deflating his useless, emphysematous lungs.

This somewhat surreal and yet surprisingly uplifting experience was repeated in subsequent visits. Being aware that he had two incurable and progressive conditions, I kept wondering how long he could last. I did not give him more than a few months. If I had made a bet over it, I would have lost. He lived at home with his ventilator, and his cancer, full four years after his admission, with no further need for hospital care. According to his wife, he never complained, and the smile never left his lips. 

Elisabeth Kübler-Ross has described the five stages of grief after a significant loss: denial, anger, bargaining, depression, and acceptance. I do not know if Yianni had gone through the full range of emotions before he came to me: he was already in acceptance mode. He had adapted to the inescapable reality of his condition; he faced every day with equanimity, indeed with joy, opting to live with his limitations and not revolt against them. I have no other data to prove my suggestion, but I believe that Yianni’s cheerful outlook played a considerable role in his long survival against the odds. He lived and died as a happy man, faithful to the spirit expressed poetically by James Whitcomb Riley (1849–1916):

It hain’t no use to grumble and complane;
It’s jest as cheap and easy to rejoice.—
When God sorts out the weather and sends rain,
W’y, rain’s my choice.