Making Rounds and Oscar (2010) (13 page)

Joan's words echoed in my mind as I drove home. I suppose after Robin's story I should have been thinking about Oscar and his sprint down the hallway, but what her mother said had struck a much louder chord. I thought about my own health and the difficulties I had finding a diagnosis for my arthritis. Initially, I was relieved when I finally learned the name of the disease that had so rapidly changed the way I led my life. At last I knew what I was up against. I could wage my personal war against a named adversary. It felt very much like a war. I was going to beat it--if I died trying.

But Joan was right. Ultimately, it ceases to be about the name of the disease; it's about the need to maintain a normal life, to be able to live life fully and in the moment despite the diagnosis. I thought about my own functional limitations ten years into arthritis and how they have forced me to make changes in my life. I could no longer play tennis, downhill ski, or play basketball like I used to. Nevertheless, I was still able to get out of bed every morning and do the things that kept me independent. I could still button my shirt and tie my shoes. Most importantly, I could still carry my children up and down the stairs--something I feared might not be the case the day my son was born. I knew that one day these very activities might not be possible, but I was thankful that I could do them today.

Today I can and that is enough.

I went home and said hello to my wife.

"How did it go?" she asked.

"Okay. Joan and her daughter are really nice people. It was tough for them, remembering it all. They both really loved Larry."

"Was Oscar there at the end?"

I chuckled. "You know, when I first heard about Oscar, I thought everyone was just plain crazy. But the more I listen to all of these stories, it seems he's there almost every single time. The families all seem appreciative."

"Maybe we should open up a cat medical school and put you doctors out of business once and for all."

I rolled my eyes and turned to leave the room. I knew she was teasing, but she had that look in her eyes. The wheels were definitely turning.

"Hey, where are you going?" she asked. "I want to hear more."

"Upstairs to take a shower."

She looked puzzled. It was only late afternoon.

"My joints hurt a little," I said. "The shower helps."

She shrugged.

I closed the bedroom door and got undressed.
Today
, I said to myself,
I take nothing for granted
. For the first time since perhaps my childhood, I thought about nothing else but the process of taking off each item of clothing. I undid the buttons on my shirt with a Zen-like deliberateness. I untied my shoes and took off my clothes, hanging them neatly in the closet. I turned off the autopilot and allowed myself to exist solely in the present. Nothing mattered but that very moment, and the next.

As the water streamed down from above, I felt the simple pleasure of it hitting my aching shoulders and back. It was warm and comforting and I was so very grateful for the simple pleasure of being able to bathe myself.

I was interrupted by a knock on the door. It was my wife.

"You okay, David?"

"Thanks, honey," I replied. "I'm fine."

Yes, it really is all about function and about learning to play the hand you're dealt.

CHAPTER SIXTEEN

"Which is more beautiful, feline movement or feline stillness?"

ELIZABETH HAMILTON

"DAVID, CAN YOU STOP BY? I DON'T LIKE THE WAY SAUL
looks. I think he's becoming septic."

It was Mary, and she had reached me on my cell phone as I headed to the university for a research meeting with several colleagues. One of the many things I liked about Mary was that she did not overreact. If she said a patient looked bad, I changed whatever course I had set for myself and headed for Steere House, as I did that warm spring afternoon. The meeting would have to wait.

As I entered the unit I was greeted by a tall, well-dressed man who was standing near the nurse's station, deep in discussion with Mary. Even with his back toward me I knew that we had met before. I think it was his accent.

I rounded the desk and acknowledged the pair with a quick hello as I pulled Saul's chart off the rack with the urgency Mary's phone call had instilled. I rifled through the pages for his recent labs and kept one ear tuned to the conversation unfolding in front of me.

"Mary, my mother's going to be much better off in the hospital," the man said.

Now I remembered. I had met him in the hospital months ago when his mother, Iris Duncan, had been admitted with pneumonia. There had been nothing extraordinary about her admission, and she had rebounded rather quickly, but I had spent considerable time talking with her son about his mother's care and her declining condition.

He was full of questions, which was to be expected. His mother had a serious disease that was progressing and anyone would have been looking for answers. But the tenor of our conversations suggested to me that he had not yet come to grips with the terminal nature of his mother's condition. He seemed to be in a state of constant negotiation. "What if we try
this,
Doctor?" he would ask, invoking some medicine or procedure he had heard of or read about on the Web. When I had explained why one tactic wouldn't work, he had been quick to suggest another. Listening to him now, I could tell that nothing had changed.

"George," Mary was saying, "your mother's really not doing well. I think she's got another bout of pneumonia brewing and with the infection she's more confused than ever. Are you sure you want us to send her over to the hospital again? You know, we can treat her with antibiotics here in the nursing home where we all know her and she's comfortable with her surroundings."

The offer sounded reasonable and for a moment George seemed to waver from his initial insistence that his mother be rushed to the hospital. Maybe he could be persuaded that keeping his mother in the nursing home would be in her best interest.

He turned to me.

"It's Dr. Dosa, right?"

"How are you, George?" I was glad to have overheard Mary using his name.

"It's good to see you again. Will you be taking care of my mother when she goes to the hospital?"

I shook my head no. "One of my other colleagues is covering the hospital this week. But I do know your mother, George, and I agree with Mary that her dementia is getting worse. She's usually out here, sitting by the desk--and she's always been quick with her hellos in that delightful accent of hers. Lately, though, I haven't seen that same resilience. If you like, I can give your mother's doctor a call. I think treating her here would be in her best interest."

But his mind was made up. As George walked away, Mary turned to me.

"How do you know George?"

"We met a few months back when his mother was in the hospital. I think we talked for almost an hour on one occasion. He had so many questions about his mother's care. He literally wanted to know everything."

Mary laughed. "He's very involved. Even when he's traveling for his job, I get phone calls from him every day: 'How's my mother doing? Is she eating? Resting okay?'" She sighed. "Though, honestly, I hope that when it's my time, one of my kids will be as involved with my care as George is with his mother's."

"I tried to talk to him about hospice for his mother before," I said. "Did they ever get involved?"

"He's nowhere near ready for that, David."

But she may be,
I thought. "What's her condition now?" I asked.

"Same as before. The X-ray says she's got pneumonia again, and she's confused."

"Has Oscar been by?"

Mary laughed. "Of all the patients on the floor, Oscar probably hides from her the most. She's always chasing him. Half the time, she tries to pull his tail. I'm not sure Oscar's going to want to be there when she goes."

"Is she still full code?" I wanted to know whether or not we would conduct CPR if her heart or breathing ceased.

"Uh-huh."

"I remember the first time I met her in the hospital," I said. "Even when she was ill, she was so vibrant!" Her smile could light up a room, but she had deteriorated since then.

"There are times when I still can't believe what this disease does to people," Mary said. Her thoughts must have been running on a similar track. "I think Iris has actually been at Steere House longer than I have. When she was first admitted to the dementia unit downstairs, people used to confuse her for one of the staff. She was such an educated, articulate woman. I think Columbia University actually gave her a college scholarship to come there from St. Kitts."

"So
that's
where the accent is from!"

"When I first met Iris, she was actually tutoring some of our aides downstairs on their English," Mary continued. "She was also an ordained minister, and I remember hearing her talk to at least one aide about her faith."

Mary smiled at the memory. "I always thought it was funny that she could still teach English and recite the Bible, chapter and verse, despite her condition. You never lose those teaching skills, I guess."

"But you called me about Saul," I reminded her.

"He may very well be the
second
hospital admission today," she said. "Go take a look at him and see what you think. You'll find Barbara there. She's very concerned." With that Mary turned toward her office, a copy of Iris Duncan's chart in her hands. As I left she was calling the medics to bring her to the hospital.

ONE LOOK AT SAUL
and I understood Mary's concern. He was in bed rather than his recliner. The television was off and there was no life in his eyes; he seemed unable to keep them open for even a few seconds. His daughter was seated at the bedside, holding his hand.

"How's he doing?" I asked.

Barbara stood up and looked at me. I could see the worry in her face. "Not well, Doctor. Mary called me in to see him."

She stood aside to allow me to examine her father. I measured his blood pressure and confirmed that it was low. I felt his thready pulse and listened to his lungs. As I examined his legs, it was obvious where the infection was coming from. They were red and swollen. An area near his shin was openly weeping, a result of cellular fluid being pushed to the surface from damaged cells.

"He's pretty sick, Barbara. I think he may be septic, a condition where the bacteria in his leg have gotten into his blood."

She nodded but said nothing.

"You know, I don't think we can handle this degree of illness over here. We're going to have to make a decision about whether to hospitalize him."

"Whatever you think, Doctor." This did not sound like the woman who had always been so resistant to the idea of not treating her dad. I decided to use this opening to revisit his end-of-life wishes.

"Barbara, I know when your father was first admitted, you had requested that we do everything in our power to restart his heart if it stops. I'd like to talk about that if we could."

"Well, if you can save him, I think you should try."

"You know, it's not like it is on TV."

She gave me an odd look and I felt like I was in danger of crossing a line but persevered.

"On television, they always get everyone back," I said. "It's not like that in real life."

"I know that," she said rather coolly.

"In cases like your father's, where someone has a chronic medical illness like dementia, we're very rarely able to get someone back if their heart or breathing stops. On television, patients almost always survive. In reality, based on your father's age and his medical problems, I very much doubt we'd ever get him out of the intensive care unit."

"Why wouldn't we do everything in our power to save him?" Now there was heat in her voice.

"Sometimes, when patients are really ill, all we are doing is postponing the inevitable and inflicting more pain. Regardless of whether we fix his infection, he'll still have the dementia. We could always keep him here and make him comfortable."

Barbara looked at me with anger.

"Doctor, my father wanted everything done to keep him alive. Even if there's the smallest chance that he can recover, I think he would want that. I'm not going to change his wishes now."

I wasn't surprised by her response. I was a traveling salesman pitching an unpopular product: the reality check. I considered reminding her that her father's circumstances had changed, but I resisted the temptation. It wasn't going to change anything.

"Doctor, I don't want to talk about any of this right now. My father needs medical attention and we need to get him to the hospital immediately."

I left the room to start making preparations for Saul's transfer. As I sat at the desk staring off into space, thinking about all that had just transpired, a visitor appeared from out of nowhere. Walking along the length of the front desk, Oscar came toward me and sat down next to the telephone. His eyes fixed on me.

"Why don't you go talk to Barbara, Oscar? Maybe you can convince her."

He looked at me and for a second I imagined that he was considering my request--as if a cat would do what you wanted even if he could understand you. Instead he rolled on his belly in front of me in an invitation to scratch him. I reached over and paid my due diligence as he began to purr.

"You're really just a cat, aren't you?"

CHAPTER SEVENTEEN

"People who love cats have some of the biggest hearts around."

SUSAN EASTERLY

"THERE WAS A TIME WHEN I THOUGHT ABOUT WRITING
a book about my experiences with my mother. I even had a name! I would call it
The Lady Upstairs Who Looks Like My Mother.
"

I was sitting in the parlor of Jack McCullough's house in East Providence where he was telling me about Oscar's first patient, his mother.

"I had to learn to love my mother as the person she had become," he told me. "She looked like the person I grew up with, but she was different."

At that he leaned back and smiled wistfully.

It had taken a while to get up the nerve to call Jack. Unlike the other people I had interviewed thus far, I didn't know him. But Jack's mother, Marion, was widely considered to be the first beneficiary of Oscar's many vigils. She passed away in November 2005, when Oscar was still just a kitten. Not only that, but a little more than a year later, Jack's aunt Barbara also died on the third floor with Oscar at her bedside. His was the first double-Oscar family that I knew of and I figured if anybody could lend some insight into why Oscar does what he does, Jack would be the man.

"Call him," Mary had ordered one day as I ruminated about whether to contact him.

It's an odd request to make, though, no matter how many times I'd done it already. "Hey, would you mind if I come over and talk to you about the cat who was with your mother when she died?"

But Mary was right. Jack had answered me with an emphatic
yes
.

"I'd love to talk to you about Oscar and what he meant to me," he said.

The house was quaint, practically historic: The furniture was antique and had likely been passed down from generation to generation. We sat across an old coffee table from each other in a pair of recently upholstered wing chairs. Everywhere there were reminders of Jack's mother Marion and her sister Barbara.

In one corner there was a photo of a grayish tabby cat, a pet from years ago, I imagined.

"Was your mother a cat person?"

Jack chuckled. "
That's
an understatement! My mother grew up on a farm in southern Massachusetts. From her early childhood, she was always collecting stray kittens, feeding them with baby bottles and droppers. Her family always used to tease her and call her 'Momma Kitty' growing up because of all the little cats that would follow her around the farm." Jack leaned over to pick up another gray tabby that had ambled into the parlor to assess the new arrival.

"Dr. Dosa, this is Bijou. I always used to say that Bijou was a reincarnation of Mittens, the cat we had growing up." He pointed to the picture of the tabby. The two were almost identical.

He put the cat down and it scurried out of the room with incredible speed. "My mother always had this uncanny attraction to cats," Jack said. "I suppose they felt safe with her. Even cats that would not come to anyone else would jump onto my mother's lap. When I first got Bijou, my mother already had significant dementia and she lived in the apartment above me. I'd come home and look everywhere for the cat, and then I'd go upstairs and find him sitting with her."

Jack excused himself to make a pot of coffee. He handed me a small photo album before he left.

"I put this together shortly before my mother died. I used to bring it to her and we'd leaf through it and look at the pictures together."

The album was beautiful and well constructed. Thick expensive paper, expertly bound--it was the sort of thing Jack might have crafted himself or bought at a specialty store, not the local five-and-dime. As I admired the album, I realized how important the project must have been to Jack, how it must have helped him explore the very essence of his mother's life story and perhaps, if such a thing is at all possible, to prepare for her death. The book was his lasting tribute to his mother, and a way to invoke the more pleasant memories from earlier in her life.

It's ironic that, while Alzheimer's and other dementias rob their victims of memory, they leave the family and loved ones with
only
memories. It can be difficult for adult children to recall the father who liked to take them fishing or the mother who pored over their homework with them. Personal mementoes such as the one Jack had assembled can help.

I leafed through the pictures. There were snapshots of Marion's journey from childhood to adult life, culminating with pictures taken at Steere House. As I turned the pages that held so much meaning for Jack I was struck by how composed Marion appeared in all of the photographs. Even in her later years, she was an attractive woman, well dressed in fashionable clothes, with beautiful hair and a glowing complexion.

I paused to study one of the photos. A young Marion was captured sitting off at a distance from the photographer, and she was looking at something just out of view. In her expression was contentment, perhaps a little mystery. Jack returned with the coffee and I put the photo album down on the table.

"That's beautiful," I said. "I'm curious: Did the album help stimulate your mother's memory at all?"

"Sometimes," Jack said, pouring the coffee and proffering cream, "although I think it was more important for me."

"How so?"

"Well, you forget so much about the person when they have dementia. You look at them and forget all the memories from before. They're still there in front of you and they remind you of that person from long ago, but they're not the same. You definitely have to learn to love the person they become."

He offered me a freshly baked muffin that I inhaled.

"I know you wanted to talk to me about Oscar the cat," Jack continued as I nodded with a full mouth, "but I really think you should know a little more about my mother."

"By all means," I said, taking a sip of the coffee.

"I used to say that I had to make an appointment to eat lunch with her." Jack smiled. "Even in retirement, Marion led a busy, full life--whether it was with aerobics, her church, or any of the other things she was involved with. She was a woman with a good heart. She found the greatest joy in the simplest things: taking me and the neighborhood kids for ice cream, or starting up the car to chase after a fire engine that had just passed by our house. I mean, how many parents actually do
that
?"

He paused for a moment of happy reflection and then added, "She was a great mother, but she didn't have it easy. My mother was a single parent."

"Really?" I said. I realized that there was a lot I didn't know about Jack or his mother. "Was she widowed or divorced?"

This is not a question I'd ask a single parent today, but single parents were something of a rarity in the fifties, and I wanted to know more about this glamorous, kindhearted woman who would go out chasing fire trucks with her kids.

"Neither," Jack replied. "In 1951 my mom met a man she fell in love with. It was accidental--and instantaneous. He was the one true love of her life. They were together for forty-nine years until his death a few years ago."

"I'm confused," I admitted.

"My father was married to someone else," Jack said. "My parents had to keep their relationship a secret. They had an affair that lasted for almost fifty years--though I prefer the word
relationship.
I was the product of that relationship."

Jack paused to gauge my reaction. He looked me over, studying my features for a hint of a reaction. In today's world, this might not seem so surprising. But 1950s Rhode Island was a different universe altogether and it was clear that Jack's upbringing had not been conventional.

"I used to say that I got to know my father from the reflection in the rearview mirror of his car. He would pick us up and we would just drive somewhere--sometimes he would take us for a bite to eat and other times we would go to another town or place where people wouldn't know us."

Jack paused for a moment to sip his coffee.

"Dr. Dosa, to understand my mother, you have to know that she woke up every day and got dressed impeccably just in case it was a day she could see my father. She never stopped looking over her shoulder for him and that behavior never stopped--even in the midst of her dementia."

I thought about the pictures I had seen: Marion with the carefully applied makeup and the beautiful outfits. Suddenly they made a different kind of sense.

"More than you want to know?" Jack asked.

"Not at all," I said. "Not at all."

The mysteries of the human heart are not confined to medicine.

"These days, when I think back about the early stages of my mother's disease, I realize how naive I was," Jack said. "Maybe you just don't recognize the early stages when it's your own mother or father. You make excuses for the little things. On one occasion, in the early eighties, I had to drop off my car at the mechanic. We had agreed that my mother was supposed to pick me up. Obviously this was before everyone had cell phones. I remember sitting at the garage waiting for her for over an hour, but she never showed up. When I finally got home, I found that she had gone off on another errand. 'Was that today?' she asked me when I caught up with her. 'I guess I just plain forgot.' In retrospect, I can see that this was probably the beginning, but I just let it go."

Jack rattled off a series of mishaps, equally trivial if taken out of context. "I remember she started to lose her keys. When she couldn't find them, she'd blame me for hiding them. I would try to reason with her, asking what possible motivation I might have for hiding her keys. It didn't matter. Each time she lost them she was convinced I had hidden them."

Jack shook his head and smiled wryly. "One time she left them at the supermarket on the deli counter. On another occasion, she locked them in the car--with the car still running!"

He was actually laughing now, though I was quite sure that none of it was funny at the time.

"You know, Dr. Dosa, you make excuses. I would tell myself she was just tired. I would tell myself she was simply mad at me for suggesting that she sell the house she had lived in for so many years. Eventually, though, I couldn't bury my head in the sand anymore.

"For me, I suppose the straw that broke the camel's back occurred several years after her symptoms began. Now, subconsciously I must have known that my mother was having trouble with her memory because I started secretly placing my business cards in her purse when she wasn't looking. I don't know why I did it, but I guess I realized that she might need me one day and not know how to reach me."

Jack smiled at his deception.

"Sometimes she'd find the cards and ask me about them. I'd tell her that they were there just in case, and she'd get angry with me. She'd rip them into pieces in front of me or simply throw them out. Luckily, though, she didn't find them all. I was at my job one rainy day when I got a call from a mailman in another part of town. He asked me if I was Marion's son and told me to get over to the Eastside as quickly as I could. Not knowing what had happened, I was frantic. I raced out of my office and jumped in my car. I remember very little about the ride over, but I must have been going through worst-case scenarios in my mind."

How terrifying this must have been, a call from a stranger on a cold, rainy day. The need to drop everything and just leave, not knowing what you're going to find. Naturally he assumed the worst.

Jack glanced off and for a second I felt he might cry. Everyone else I had talked to had. But he composed himself and it occurred to me that maybe he was done with crying.

"When I found her I remember thinking that this was as bad as you can probably ever imagine. You never
ever
want to see your mother the way I saw mine that day. She was drenched to the bone and completely confused. It was clear that she had been crying and her mascara had all run down her face, making her look like some tragic clown. I asked her where her car was and she broke down in front of me...she had no idea. She was so completely lost!"

He paused in his telling. He was reliving every brutal second of that day as if it were yesterday. When he began again, his voice was low and halting.

"You want to know the funny thing? Even the car event didn't really bring the disease home for me. I knew my mother had a problem, but I hadn't put it all together. It didn't occur to me until a few weeks later when I was at a party. I was telling a friend about the incident and he casually asked me if my mother had Alzheimer's disease. It hit me like a ton of bricks."

Jack shook his head sheepishly.

"All of these events were happening, and I didn't realize that my mother had Alzheimer's until someone uninvolved casually mentioned it at a party! I was in denial."

As he uttered the
D
word, I couldn't help but think how many people were like Jack. We all make excuses rather than deal with what we don't want to see--even if it is right in front of our noses.

"Mom's just tired today."

"Dad's just got too much on his mind."

We minimize symptoms despite a preponderance of evidence. We acquit the victim and avoid the obvious. The mind really
does
work in mysterious ways.

"After my mother was diagnosed, I realized I needed to move her closer to me, so I relocated her to an apartment above my own. Thankfully, she let me take over her finances with minimal resistance and I eventually began taking her to the local senior center so I could go to work during the day. At first she complained bitterly, but I was persistent. I had no choice. But if there's a silver lining with Alzheimer's it's that they stop complaining as the disease gets worse. After a few weeks of resistance I think she actually enjoyed the senior center. Regardless, it only worked for a time. She became increasingly difficult for me to care for and I had to hire people to help, to make sure she got dressed in the morning, took her medications--and to make sure she didn't disappear out of the apartment while I was at work!

"Her personality also changed," Jack recalled. "She would swing from one extreme to the other almost minute to minute. My sweet, loving mother became paranoid and mean--something she
never
was earlier in life. I would be at work and receive a phone call from an aide who would be in tears over something my mother had done. I would run home and find this docile, sweet woman with no memory of having done anything untoward. Over time, the personality changes became extreme.