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Introspections   |    
M. Katherine Shear, M.D.
Am J Psychiatry 2001;158:1588-1589. doi:10.1176/appi.ajp.158.10.1588
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Sam was 77 years old when he underwent angioplasty. Two days later, his anticoagulant was inadvertently discontinued, and he experienced a cardiac arrest. After 8 months in an intensive care unit, during which time he survived a pulmonary embolism, an episode of Gram-negative sepsis, and countless other assaults on his body, his doctors began the slow process of weaning him from a respirator. He suffered a period of delirium in which he seemed to be reliving his version of World War II, before they finally succeeded. Next, Sam needed to regain the use of his bladder, to become strong enough to eat alone and walk, and to recover a bit of his sharp intellect.

None of this would ever happen, according to his newly assigned geriatrician. This busy doctor had not had time to carefully read the huge chart and did not seem to consider that Sam might have entered the hospital in relatively good condition. Convinced that Sam’s impaired mental status and his physical infirmity must be both long-standing and permanent, the doctor pushed strongly for discharge to a nursing home.

A review of Sam’s 77-year biography indicated, however, that the doctor might be wrong. Sam’s family resisted nursing home care, making a strong case that Sam needed his freedom and insisting that they could provide the support to enable him to resume independent living in the home he loved. They explained that Sam was a snappish, strong-willed person who was used to having his way. He had suffered throughout his life from episodes of irritable depression, although they were not diagnosed or treated. His family were concerned about a recurrence of depression. Sam had responded to a psychiatric consultation in the hospital with contemptuous belligerence. Yet his family also knew him to be a fighter. As they prepared for Sam’s discharge from the hospital, his family understood that if his will were not broken by banishment to a nursing home, he would bring his determination to bear on his current situation.

Sam was known for his perseverance and force, although his ideas were sometimes idiosyncratic. Fighting and scheming, he had pushed his way through life, grabbing prizes, only to spend them again—always in search of something more. As it turned out, even during his medical ordeal, Sam clung tenaciously to his goals, calling his stockbroker during moments of lucidity in the intensive care unit, without consulting anyone else. His family learned only after his death that he had successfully traded puts and calls during this period.

Sam was the eldest son of Jewish immigrants, a family plagued by poverty and sometimes the brunt of anti-Semitism. He took care of his younger sisters, and he remembered pushing the youngest around the neighborhood in a baby carriage every day after school. He used to brag about his first job sweeping a shoe store at 9 years old. His father committed suicide in 1929, when Sam was 19. Deeply affected by this, but undaunted, Sam put himself through college and then law school and eventually he became a successful businessman. His hobby was coin collecting, and other collectors often turned to him for advice, considering him a highly knowledgeable numismatic historian. Sam was a risk taker and a storyteller, opinionated and headstrong.

Notwithstanding his brashness, Sam had a generous side. Throughout his life, he had freely shared his good fortune. If he thought a person worthy, he would loan money without even a promissory note. Sometimes he would surreptitiously slip $100 into a needy person’s pocket. If he thought a friend or relative would especially appreciate something he owned, he would insist that they take it. He stuffed the closets full of toys and games and trinkets to give away to children, loving when they visited. Sam made friends easily and with people from all walks of life. He was always eager to help at difficult times in a person’s life, be it a waitress, a coin dealer, a struggling colleague, or his own brother. His family thought he deserved to be treated in kind.

With their support, Sam eventually returned to his high-rise apartment. He loved to watch morning sunshine flood the hardwood floor, and evening shards of mauve-stained clouds vanish over the horizon. From this place he called his "palace in the sky," he could see the leaves change in the park across the street. Because he could not be alone, and his wife’s job frequently took her out of town, he needed a nurse. After firing at least six, he finally accepted a woman named Pat. Outspoken and blunt, Pat was not intimidated by Sam’s grumpy demeanor. Over time, they became fast friends. Sam trusted and relied on this camaraderie.

Sam had always been very frightened of death. He would become enraged if asked about his cemetery plot. Pat, a devout Catholic, eventually found a way to shepherd her nonpracticing Jewish charge to a place of spiritual comfort, so that he could visit a cemetery peacefully and even talk about his own death. Observing this somewhat astonishing change in cantankerous Sam, his family learned their own lesson—that psychological growth is not restricted to youth, nor is it the sole province of the contemplative, but it can come even very late in the life of a sick, ornery old man.

And so it happened, 3 years after his discharge from the intensive care unit, the patient written off as "hopeless" by the geriatrician celebrated his 80th birthday. Sitting at his dining room table, surrounded by children and grandchildren, he held forth, "How many men does it take to change a roll of toilet paper?" Sam asked. The answer: "No one knows. It’s never been done." Although he died 9 months later, he had escaped a 3-year "sentence" to a nursing home—an experience that almost certainly would have broken his spirit. Instead, his family regained their familiar irascible Sam, who, with his fear of death greatly diminished, was accessible to them in a new way.

As I observed this story unfold, I was reminded of many things: that critically ill elderly patients can be remarkably resilient, that a family can and should play a crucial role in caring for senior loved ones, that death with dignity can and must be preserved in our growing population of senior citizens, and that in some circumstances our nursing colleagues have access to patients when we do not and can create an environment that facilitates important psychological growth even in an elderly debilitated person. Above all, I was reminded that we never stop growing, even as we age and approach death.

Address reprint requests to Dr. Shear, Anxiety Disorders Prevention Program, Western Psychiatric Institute and Clinic, 3811 O’Hara St., Pittsburgh, PA 15213-2593.




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