Jeez mate, you are really dead. "Really fucking dead," as you would say. I don't need to be a doctor to know that. The cop who rang me was right. You must have been sitting in your lounge chair, dead, for at least twelve hours, maybe more. Looks like you were enjoying a quiet drink when you checked out.
I’ve got to tell you mate, it's pretty weird sitting here at your dining table, with you there, slumped over all mottled and cold, while I'm trying to fill out your death certificate. With your advance-care directive staring at me from on top of all your papers on the table. Was it left there as a gift for me? I did feel a little better when I read that you wanted to be allowed to die a natural death. That you didn't want any more medical interventions (God knows, you'd had enough of those already). That you wanted to die in your home.
Was it the chemo that knocked you off in the end? That's what I want to believe. Because if it wasn't that, then it might have been the high potassium level in your blood. When you visited me yesterday at the office, I told you that a level that high could kill you. I urged you to go to the hospital.
I couldn't have made the risk much plainer: "You could drop dead at home, mate."
Your reply was just as plain: "I don't give a rat's. I'm not going back to the fucking hospital. You can carry me out in a coffin for all I care--I'm not going back. I've got the treatment I need at home. I'll take it there. Stuff 'em."
Maybe you didn't believe this would happen to you. Or maybe, just maybe, you'd really had enough and were ready to go. I'll never know. And I can't ask you now.
There were so many things that could have killed you. Didn't your heart specialist in Sydney say you wouldn't last two years when you moved out here to the country? Well, we proved him wrong: you got a decade. Even with the feeble heart. And the failing kidneys. And the out-of-control diabetes. And the ulcerative colitis. And the bowel cancer. And its secondaries.
I wonder about your last moments alive. Did you feel death coming? Was there pain? Did the defibrillator in your pacemaker keep firing, trying to get your heart going again? Did you have time to be scared, or was it over before you knew it? At least you died in your favorite chair with a glass of your favorite whiskey by your side. Give me that death any day over a failed resuscitation in the hospital.
I hope it was the chemo that did it. Reckon it must have been. You wound up in the hospital the last two times you had it. Don't the oncologists know when to stop? But you seemed keen to keep going. Still seemed to have reasons to live.
I wonder what kept you going the last few years. After all the time you spent caring for your wife before she died, watching her disintegrate before your eyes. After having to put up with the colostomy bags following surgery for a preventable cancer--one that a colonoscopy would have picked up in time if you hadn't had to wait so long for it. After having to see all those medical people: cardiologists, gastroenterologists, nephrologists, bowel surgeons, diabetic educators, dietitians. You had a nickname for each of them. Perhaps that's what kept you going--your sense of humor. And your ability to see that people were genuinely trying to help you, despite the health system's failings.
The truth is, you didn't get that colonoscopy in time. I wonder if I could have done more to get it for you earlier--before your inflammatory bowel disease, well controlled for so many years, turned into bowel cancer. I made the referral at the appropriate time; I didn't know that the public system's waiting list would be so long. If I'd known, I would have encouraged you to go private--or helped you to conjure up some symptoms that would have bumped you up the line. The retrospectoscope makes it seem so easy.
Those conversations we shared about your precarious future--were they helpful? I knew what was coming, and I wanted to give you an idea of where things were headed. The conversations were difficult for us both; I appreciated your acceptance of my honesty. You needed to know the truth. No one else in the health system was going to tell you. You and I had been through so much together. It was the least I could do.
You got your will sorted out. You patched up your differences with your daughter. You even found a home for your cats.
I just hope it was the chemo that got you, and not the high potassium level.
I don't want to spend the rest of my life thinking that I might have killed you. I tried to phone you this morning to tell you what dose of the drugs to take today to get your potassium lower, but you didn't answer. I rang your home phone and your mobile; you always answer your mobile. I kinda knew then that something had happened. I was going to drop in to check on you on my way home this evening.
It does feel strange being in here with you, and you being stone motherless dead. You were so alive when I saw you yesterday. Still, I wished the ambulance medics hadn't left so quickly when I arrived. I would have asked them to help me lay you down so that you'd look better when your daughter turns up. I'll give her a call in a minute to let her know what to expect when she gets here. I reckon you'd want me to do that.
Well, this is it, mate. Sorry that the first time I got to visit you at home was to sign your death certificate. But we kept you going ten years longer than your Sydney specialist thought we could, so it's not all bad.
I'm going to miss you. You visited me more often than any other of my patients, you were that sick. Did I ever tell you that you were my most frequent flyer? I think you felt that I helped you. I hope so. We had a few good laughs. Did that ease your burden a bit?
I'll miss your swearing. Who else is going to answer my innocent "How's things?" with "I'm fucked and far from home, mate."
I'll miss the nicknames you used for all the doctors you had to see. Like how you called Dr. Cornwall "The Duke," Dr. Curtin "It's Curtains For You," and Dr. William James, who is so prim and proper, "Billy Jim." And who's going to call me Hilti now? You were the only one to do that. You're going to be a tough act to follow.
So see ya later, mate. 'Cept I won't, of course. And that's the whole point.
About the author:
Hilton Koppe is a family practitioner in the seaside village of Lennox Head, on the east coast of Australia, and senior medical educator for the North Coast GP Training program. The combination of clinical work and teaching sustains him personally and professionally. Seeing himself as more of a teacher than a writer, Hilton runs critically acclaimed creative writing workshops for health practitioners around Australia, Europe and North America. (To learn about how these writing workshops came to be, visit http://vimeo.com/39318488.) Hilton's writing has appeared in Pulse, The Examined Life, Australian Family Physician and Primary Care. "As a family doctor in a small community for twenty-five years, it can be hard to say goodbye to people I have known and cared for over a long time. This particular piece helped me to farewell one of my favorite patients. (But please don't tell anyone that I have favorites. We're not supposed to do that!)"