Commentary

Old Stone Face

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O Romeo, Romeo! Wherefore art thou, Romeo?

As I read John Miller’s obituary I barely recognize the man; it takes up a quarter of a page in The Seattle Times, and it emphasizes his leadership skills, his philanthropic activities, and his humor. It’s the latter that I find hard to believe. But then, I never did figure him out. I remember him as Old Stone Face. He was 86.

When I met him nearly 8 years before his death he had just retired from the law firm he co-founded and built into one of the most prestigious in the city. I admit I knew only a narrow slice of the man’s life. But it was an important slice. It was a week in which I tried to convince him that his wife would be better off on no-code status.

John and his wife, Mary, were an associate’s patients, but since he was on vacation I got the call on that last Sunday morning in June. It was Mary’s private nurse who asked me to come to the home and examine her. “Mrs. Miller might need hospitalization,” she said, “but it’s so difficult to move her.” When I got there I could see what she meant. Mary suffered from rheumatoid arthritis and for many years had been on large doses of prednisone prescribed by her rheumatologist. She had, without doubt, the most advanced case of Cushing syndrome I had ever seen. Her whole body was moon shaped (not just her face) and was covered with ecchymoses and weeping abrasions. Her hair had been reduced to fuzz. She reminded me of a bruised decaying peach. I hesitated to touch her, fearful that I might further tear her tissue-thin skin.

Their home was a different matter. It was an elegant and charming Mediterranean villa located in an exclusive, gracefully landscaped, in-city neighborhood. The front entrance to the house opened onto a gray slate central plaza will a full-size grand piano. The living room, dining room, and a large study area all opened out directly from the plaza. Mrs. Miller, her bed, and all the contraptions necessary to care for her occupied the study area; 2 of its walls were lined with books, and the third, all glass, opened out to a stone patio. Mt. Rainier could be seen from the patio, clear as a painting in all its distant grandeur.

Mary lay on a pressure-sensitive air mattress, an elaborate orthopedic frame was fitted over the bed, and a urinary catheter drained into jug half filled with dark smoky urine. Her oral temperature was 103 degrees. She was semicomatose, dehydrated, and hypotensive. I thought septicemia from a urinary tract infection was the most likely diagnosis.

It was the nurse who gave me the history and helped me examine Mary. John said very little. Instead he walked around, patient but distant, still dressed in his morning robe. He was tall and thin, his facial features sharply sculpted, and his hair, iron-gray, was combed straight back from a high forehead. I quickly got the impression that he was only tolerating my doctoring and already knew what should and would be done about it. And he was right. An ambulance was called, and Mary was transported to the hospital.

Later that afternoon when I had a chance to sit down and review her hospital charts I learned that Mary had been hospitalized 3 times during the past year in virtually the same predicament. And now, as on her previous hospitalizations, she was comatose.

Her creatinine level was higher than expected from dehydration alone. I increased her drip rate of glucose and half normal saline, started her on the same antibiotics given before, and awaited the reports of her blood and urine cultures. To me her future looked hopeless: Something in this friable body was bound to burst or crumble. This might be the right time to let her slip quietly away.

That evening at home, after some stewing, I decided to talk with John about his wife’s treatment and code status. In the morning I would at least recommend she be made no code. Why bring her back to go through this again and again?

On Monday I found Mary still in a coma. John was sitting quietly as I found him every day, alongside Mary’s bed reading The Wall Street Journal. After my examination I asked John to join me in the floor lounge to discuss her situation. It was there that he, without changing his solemn expression—without any show of emotion at all—insisted that Mary be treated actively, that she be kept on full-code status throughout the duration of this hospitalization. I explained that her ribs would fracture with cardiopulmonary resuscitation; if she were revived she would only have to go through this again, and now, if she had a cardiac arrest, would be a good time to let her slip away. Nothing doing. It was then I first thought of him as Old Stone Face.

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