In Your Words  |   August 2015
A Physician’s Living Will—‘Till Death Do Us Part
Author Notes
  •  *Address correspondence to Lubaina S. Presswala, DO, St John Medical Center, 29000 Center Ridge Rd, Westlake, OH 44145-5293. E-mail:
Article Information
Gastroenterology / Medical Education / Practice Management / Being a DO / In Your Words / Graduate Medical Education
In Your Words   |   August 2015
A Physician’s Living Will—‘Till Death Do Us Part
The Journal of the American Osteopathic Association, August 2015, Vol. 115, 523-524. doi:
The Journal of the American Osteopathic Association, August 2015, Vol. 115, 523-524. doi:
The rigorous demands of internship—the first year of residency—hold true the urban legend about physicians working innumerable hours on medicine wards in a state of persistent fatigue, sleep deprivation, and chronic dysthymia. Maintaining positivity during internship is a challenge; however, opportunities to touch lives makes it worth the effort. 
As interns, we are trained to be machinists as we answer an incessant amount of pages, sort through our patients on wards before rounds, recycle admissions and discharges continuously and, finally, sign out to our colleagues, only to realize that we skipped lunch and developed greater bladder capacities on any given day. Subspecialty rotations promise one-on-one training with an attending physician, a consult-driven inpatient focus, slightly fuller stomachs, and perhaps more time to appreciate our commitment to medicine. 
It was my first day on rheumatology service as an intern. I anticipated working with Dr Z, a Peruvian rheumatologist who my senior colleagues described as pleasant and well spirited. As I walked into the office building adjacent to the hospital, I saw an elderly gentleman, walking toward me in slow short strides. He pointed to the elevator and signaled for me to hold it as he limped toward it. He approached me looking somewhat pale and jaundiced. 
In the elevator, he peeked at my name on my white coat and asked me: “Are you Dr Presswala?” I nodded with a smile. He looked at me with a sparkle in his eyes, a grand smile on his face, and said, “Welcome to rheumatology, I am Dr Z. It will be a great month.” The sparkle in his eyes and the smile on his face inspired confidence in me, calmed my nerves, and reassured me that I would make it through another month of internship. 
“This is Dr Presswala, and she is my resident,” he later introduced me to his nurse in a room of the intensive care unit (ICU). This time it was Dr Z who was lying in the ICU bed as I sat beside him holding his water jug in hand. He turned his head first at her and then to me with that same sparkle in his eyes; nonetheless, a more tired smile on his face. 
Dr Z had been diagnosed as having colon cancer before I started my rotation with him. He had completed several rounds of chemotherapy and was living with the adverse effects of fatigue, hair loss, and peripheral neuropathy causing him to limp and ambulate with great difficulty. He honored me by sharing his journey while he struggled through his disease and treatment intolerability. Sadly, the most recent surveillance had shown metastasis to the liver and mesentery. 
Despite his limitations, Dr Z continued to see patients on a full-time basis in the clinic and in consultation to providers in the hospital. Dr Z had been practicing internal medicine and rheumatology for many decades, serving patients in the community and even visitors from other states. He had a thriving practice with a primarily geriatric patient population. His patients adored him for his compassion. He was admired by his colleagues and looked up to by nurses, students, and residents. Dr Z always had a student or resident with him every month. He inspired goodwill, compassion, and commitment in his training. 
As the days progressed, our schedule had fewer patients with longer time intervals. In-hospital consultations were primarily dependent on me, with his supervision. I was fortunate to have learned such an immense breadth of knowledge and skills to manage consultations with his supervision limited to procedures and treatment plans. 
Dr Z’s jaundice worsened, a peculiar maculo-papular rash covered his arms, his appetite declined, weight loss was noteworthy, and his ambulation was minimal in the preceding days of the month. Nonetheless, his will to continue serving his patients persisted and appeared to be the fuel to his strength. He concealed his struggles with his grand smile and sparkling eyes. 
I would bring him soup from the hospital cafe for our lunches. Our conversations were about his life in Peru and mine in India, our mutual passion for tennis and Roger Federer, and our decisions to become primary care physicians. He laughed and claimed to be the tennis champion at the hospital and I dared to challenge him for a match. Poor appetite and distaste were our only offending distractors to great conversations. 
I made more frequent visits for consultations, and his physician coverage gradually increased in the clinic. He was talking with another physician regarding coverage for an upcoming week on my last day of the rotation. I stood by the door; he appeared grossly yellow and notably malnourished. He introduced me to his colleague, again with that great smile and sparkling eyes, “This is Dr Presswala, and she is my wonderful resident. Good job this month on rheumatology. Thank you for all your help. It was a pleasure working with you.” 
Later that night, I learned that he was admitted to the ICU for extreme fatigue and severe respiratory distress. Although our profession teaches us that patients with cancer have a progressive deterioration, I did not know how to respond to his grave state. A sense of denial set in, followed by a realization of events and, eventually, a persistent state of heart-wrenching helplessness. The knowledge of a nearing end for a dear mentor left me weak. Despite regularly empowering families and offering sympathy to my patients in the hospital, in this case, I felt distraught as Dr Z was a part of our hospital family and it was very hard to accept that he was dying. 
I walked in with quiet steps to see a tired old man, sitting stooped forward in bed, breathing shallowly, with his eyes shut behind his glasses. A telemonitor reflected tachycardia, tachypnea, and mild hypotension. I approached him slowly and placed my hand on his shoulder. He opened his eyes, looked at me, and only attempted to smile. He cleared his throat and looked at the water jug but lacked energy to lift it. I gave him a few sips of water. “Won't you sit?” he said. His eyes quickly shut again until he was awakened by the ICU nurse. 
He was discharged to return home with hospice care and died shortly after, surrounded by his loved ones. 
It was upon hearing of his passing that I understood a physician’s lifelong commitment to medicine, patients, service, and medical education. Today, as a final-year resident, I have learned to appreciate a variety of patient experiences, my increased breadth of medical knowledge, and the significance of healing with just a smile or a touch. Every day, I grow more inspired to continue my osteopathic commitment with compassion, to nourish a sparkling energy that reflects my gratitude for being a physician, and to sincerely dedicate all of myself to service and education...’till death do us part.