Making Rounds and Oscar (2010) (17 page)

CHAPTER TWENTY-THREE

"A cat makes all the difference between coming home to an empty house and coming home."

UNKNOWN

ONE AFTERNOON A FEW DAYS AFTER RUTH'S DEATH,
I was seated at the nurse's desk on the dementia unit, scribbling a note on one of my new patients, when I was interrupted by a commotion. Looking down the hallway, I noticed Maya chasing Oscar at full speed the way cats do when they are bored. Suddenly intrigued, I stood up and watched as they sped down the hallway past Louise Chambers, asleep in her chair. Then they were gone.

The scene of cat chasing cat in innocent play made me smile. As Mary said, this third floor really was their home. I looked past Louise in the direction of the departed cats. The afternoon sun had just started to make its impression, setting the walls aglow. Soon it would illuminate much of the hallway, then fade. It wasn't a lasting impression after all. I found myself thinking about Ruth Rubenstein; her death was still fresh in my mind. An hour earlier I had stopped by her room. I lingered there alone. I studied the unoccupied bed, neatly made, and the barren walls. Gone were the pictures of her youth, her husband, her past. The room was no longer hers, save for the faint reminder of her perfume. That too would disappear in time.

The main doors to the unit clicked open, interrupting my thoughts. I turned toward the door and saw Mimi, the admissions coordinator, escorting an elderly gentleman and two younger women onto the unit. They looked like sisters. They were on a tour of the facility and Mimi was in the midst of describing the unit.

"This is our advanced dementia unit. It is forty-one beds and staffed by nurses twenty-four hours a day..."

Suddenly the door closed behind the family with a thud, locking them in with the residents. I could sense their discomfort, even from a distance. They listened politely to Mimi as she carried on with her explanation, but I could well imagine what they were really thinking:
How in the hell do we put our mother in this place? The doors lock behind you! What did she do to deserve this?
I've seen this before: the deer-in-the-headlights look of a new family.

Mimi led the tour down the hall toward Ruth's room. She pointed out key locations on the unit--the kitchen area, the dining room, and the nurse's offices. As they passed Louise, asleep in her chair, one of the daughters stopped briefly to consider her.

I could almost hear the questions in her head as she studied Louise:
Is she clean? Is she happy? Do they take care of her?

She was looking for reassurances that they were making the right decision, that they were in the right place.

I didn't envy them.

The lady moved over and studied the pictures on the corkboard next to Louise's door. For the first time since she arrived on the unit, she smiled. Then she disappeared down the hallway, chasing after the rest of her family.

I returned to the note I was writing. Something brushed against my feet. I looked down.

"Hello, Oscar."

He had finished his playtime with his sister cat and was looking up at me.

"I heard you were with Ruth when she died."

Much to my surprise, he sprang up onto the desk and sat down, staring at me as if to say hello.

Our eyes met and he started to purr.

"What's up, Oscar?" I asked, nervously reaching out my hand. "What's going on?" What if he
was
like Lassie, as I joked with Mary all those months ago, trying to say someone had fallen down the well? What if Oscar was trying to
tell
me something?

He considered my hand and then moved his face in toward it as if to say,
Scratch, stupid!

I relaxed and began to scratch under his chin. I pulled him closer and he continued to purr more loudly. We sat together, sharing a moment, before we were interrupted.

"Hello, Dr. Dosa. I want to introduce you to the Carey family."

I looked up to see Mimi returning with the family. Oscar saw them too and began to take his leave. He leaped out of my grasp onto the floor before sprinting down the hallway.

"Cats," I said, by way of introduction, and leaned over to offer my hand.

Both daughters smiled.

"Do you have any questions about the unit?" I asked, trying to be helpful.

"Do you always have cats here?" one of the daughters asked incredulously.

"Absolutely. We have two cats on this floor and four more downstairs, along with a rabbit and several birds," Mimi answered.

"That's so nice," her sister responded. She was the one who had been studying Louise earlier. She turned to the father.

"Dad, Mom really loved cats."

Past tense.

"You mean, your mother
loves
cats," I said.

She gave me an odd look, perhaps slightly embarrassed. I realized how many of the families I worked with spoke of their loved ones with dementia as if they were already gone.

"Actually," I said, letting the poor woman off the hook, "we've found that the presence of animals really helps residents in the latter stages of dementia. Your mother will know that they're here."

"Really?" the woman asked.

"Yes, I didn't really think so myself at first, but I've spent enough time up here to realize that the animals really do make a difference for the residents and the families."

The woman gave me a questioning glance that I immediately recognized. It was probably the same look I had given Mary the first time she had shared her musings about Oscar.

"I suppose there is just something about animals that still gets through." I paused for a second. "I'd like to think they have something to teach us, too."

The woman nodded and looked around, "So, what do you think, Dad?"

"I think this is the place." He attempted a smile--an effort, given the circumstances and turned to Mimi. "If it's still available and you're willing to take care of my Lucy, we'll take the bed."

Mimi nodded and escorted the family out of the unit, deep in conversation about the various forms and paperwork that would need to be filled out.

As they left, Mary appeared from down the opposite hallway, pushing a resident in a wheelchair. She parked the patient by the desk and then reached over to give the woman a hug.

The woman smiled and returned the embrace.

"What was that all about?" she asked me as she rounded the desk to sit down.

"Mimi was here with a family. It looks like we'll have a new resident in Ruth's bed."

"We always do, David. They never stay empty for long."

The afternoon sun had faded now, like words written in water. Halfway down the hall I saw Oscar appear out of one of the rooms where he had taken refuge from the visitors. He looked at both of us and paused for a moment. Then he turned and trotted purposefully down the hall in the opposite direction. When he came to the last room on the right he stopped and appeared to sniff the air. Then with a flicker of his tail, he disappeared into the room. I looked at Mary with the hint of a smile. Was Oscar trying to tell us something?

I was listening.

Afterword

MUCH LIKE THE FAMILY MEMBERS I VISITED IN THE
course of my Oscar odyssey, I have come to be thankful for what Oscar does and what he has to teach us about the end of life. But the question that people keep asking me is "How does he do it?"

I think back to a phone call that I received shortly after my essay about Oscar appeared in the
New England Journal of Medicine
. The caller introduced himself as a World War II veteran from Florida. He told me that he had been a medic in Europe during the war and that his job was to evacuate injured soldiers from the battlefield.

"Doctor, by the end of the first few months of dragging people off the battlefield, I could tell whether the person was going to live or die," he said. "If they were going to die, there was a sweet aroma emanating from their bodies. I didn't smell it if they were going to live."

There is a plausible biological explanation for that "sweet smell of death." As cells die, carbohydrates are degraded into many different oxygenated compounds, including various types of ketones--chemical mixtures known for their fragrant aroma. Ketones are also found in abundance during episodes of untreated juvenile diabetes and doctors are taught early on in medical school to sniff the breaths of diabetics to determine if their sugar levels are high. Could it be that Oscar simply smells an elevated level of a chemical compound released prior to death? It is certainly clear that animals have a refined sense of smell that goes well beyond that of the ordinary human.

A 2006 study, published in a leading cancer journal, suggested that dogs could be trained to identify microscopic quantities of certain biochemicals excreted by cancer cells on the breaths of lung and breast cancer patients. Similar studies over the years have also identified melanoma-sniffing dogs and earthquake-predicting fish. Is it outlandish to suggest that Oscar, a cat residing on a floor where patients with end-stage dementia routinely die, has merely learned how to pick up on a specific smell emitted in the final hours of a patient's lifespan?

Perhaps, but I like to think of Oscar as more than a ketone early-warning system. Ever since I was a child, listening intently as my grandfather read bedtime stories from Rudyard Kipling's
Just So Stories,
I have imbued animals with human characteristics and frailties. It could simply be that we see ourselves in them--the best of ourselves, sometimes.

On a floor where the staff has gone to great lengths to make the dying experience tolerable for the residents and their families, I'd like to think Oscar embodies empathy and companionship. He is a critical cog in a well-oiled and dedicated health care team. As the physician, it is my job to prescribe the appropriate medications and provide guidance to the family; it is the nurse's job to provide the appropriate care; it is the minister's job to provide the necessary spiritual counselling for the patient and their family; and it is Oscar's job to provide the critical companionship during the final hours. He is clearly part of the team and as much a comfort to the families as he is to the patient, though in some cases he is the only family the patient has left.

I don't really pretend to know the nature of Oscar's special gift--I am not an animal behaviorist nor have I rigorously studied the why and how of his behavior. Whether he is motivated by a refined sense of smell, a special empathy, or something entirely different--your guess is as good as mine. But I believe we can all learn from his example.

Though my interviews with decedents' families were meant to provide me with more insight into what Oscar does, I found myself learning a great deal more about the diseases that had destroyed my patients' lives than I did about the cat. For all the mystery surrounding Oscar, there was little mystery about the devastating consequences of dementia.

Today, there are over five million people in the United States with Alzheimer's disease and hundreds of thousands more with other less common forms of dementia. Without new treatments, estimates suggest that this number is likely to skyrocket as our population continues to age. But the tragedy of dementia is not measured merely by the number of patients directly affected. For every patient with dementia, there are many more caregivers whose lives will never be the same.

Recently, my wife and I joined their ranks when her mother was diagnosed with dementia. Like countless others in this country and around the world, we are entering an uncertain phase in our lives, one that will involve caring for a parent with dementia. We add this new responsibility to the myriad others of parent, professional, and spouse. Where will the extra energy come from?, we wonder. How can we find the capacity to care for yet another dependent--an adult, no less? Even though I work closely with caregivers who tackle the same issues, and have always respected their fortitude and optimism, it is always different when it happens to you and your own family. Suddenly it's personal.

After another exasperating phone call with her mother's doctors, who had nothing new to suggest in regard to her failing memory, my wife turned to me for support. "Surely from all of those interviews you gleaned some words of wisdom that might help me get through this?" While every case is different and all caregivers find their own way through trial and error, coming up with solutions as different as one family is from the next, I feel confident in making a few generalizations:

1. Take care of yourself.

As a geriatrician I have seen countless caregivers fail physically or mentally long before the patient with dementia does. There's good reason for this. Caregiving is a 24-hour, 7-day-a-week, 365-day-a-year responsibility. There is no time off for good behavior and the physical demands of caring for the elderly when they have dementia are profound. So too is the psychic strain of seeing someone close to you struggle. Remember,
no one is ever successful for long if they go it alone.
You need to share the burden of caregiving, even if it ultimately involves placing a parent or spouse in an assisted living or nursing home. You also need to maintain the body and mind by seeking the medical and emotional support needed to deal with caregiver challenges. The Alzheimer's Association has many fantastic resources; I've found their local support groups to be particularly helpful.

2. Be present.

Easier said than done--try putting aside daily work and life responsibilities and making the time to spend with someone at the end of life. Yet so many of our day-to-day responsibilities are ultimately inconsequential. Someone can always cover for you at work, and your children will forgive you for missing a soccer practice. Animals like Oscar can teach us through their steadfastness, their patience, and their presence. They don't have to be anywhere else except where they are. When Oscar visits his patients, he doesn't care what time it is or whether there is somewhere else he would rather be. He is in the moment. It is so important to be able to spend time with someone with dementia--even if you think that they no longer know who you are.

3. Celebrate the little victories but see the big picture.

Living with someone with dementia can be a roller-coaster ride. For every little victory that brings joy--an upswing in appetite, a remembrance of a name--there is the ultimate certainty of continued decline. Those that cope best with terminal progressive illnesses such as dementia are people who can gain satisfaction from a little victory without losing the larger perspective.

4. Become an advocate for high-quality care.

Our medical system does not effectively deal with patients with dementia. Certainly some institutions do it better than others, but ultimately every acute-care hospital, nursing home, and outpatient office could be improved. Being an advocate for high-quality care is about being involved and asking questions. It is also about choosing your battles and understanding the limitations inherent in dementia care, particularly in the nursing home environment. It is possible to get good care or bad care at every nursing home. What makes the difference is family involvement.

5. Love and let go.

It is my hope that, one day, dementia will become a footnote in medical history, much like smallpox and the plague are today. We will certainly be better at handling it. The treatment options available today, though, are few, and even those are seldom helpful for long. Eventually, every caregiver has to
let go
--whether it's letting go and sending a loved one to a nursing home or letting go when death is near. When this time comes, please remember that letting go of a person with terminal dementia is not a sign of defeat: It is an act of love.