For love of life
In 1991, I met a 64-year-old gentleman who had very severe coronary artery blockage. He successfully underwent quintuple bypass surgery and then came to see me on a very regular basis. This is his story — the story of a man who loved life and fought till his last breath.
For the immediate years after his bypass surgery his health remained good, but in 1995 he had a transient ischemic attack manifested by confusion and difficulty with speech. We found him to have a high-grade left carotid blockage. The carotid is one of the main arteries that supplies blood to the brain. He underwent a carotid endarterectomy by the same surgical team at Lutheran Hospital that had done his bypasses. An endarterectomy is basically a reaming out of the severe blockage in an artery. He fully recovered without any permanent neurologic impairment.
A period of stability followed, but in 1999 he showed up in my office complaining of chest pain; a coronary angiogram showed a new, severe blockage. He underwent a technically difficult coronary angioplasty to open this partially blocked artery. He then became angina-free and continued to live an active life.
In 2002, he presented with severe hypertension. I had him on just about every class of medicine available for uncontrolled blood pressure, yet I could not control it. We discovered that he had bilateral renal artery stenosis, or blockage in the arteries to both kidneys. This can be the cause of refractory hypertension, and therefore he underwent stenting of both renal arteries successfully. Another period of stability followed, and I continued to enjoy seeing him in the office. He always came with his lovely, supportive wife. He began to write short progress notes outlining how he had done since his last visit.
After a few years, he expanded his typed progress note to include either a joke at the end or an insightful comment about the state of mankind. He was a deep thinker. Some of these comments were quite profound, others just plain old funny. As I would read the note either laughing or smiling, his wife would invariably roll her eyes, pretending to be embarrassed. I could see the love in her eyes as she gazed at her sometimes-cantankerous husband.
In 2005 he came back to see me with very limiting angina. This was just not acceptable to him. He had too many things to accomplish yet in his life. My team performed another cardiac catheterization on him, and it was very bad news. He had developed diffuse disease of not only his native coronary arteries but also of his five bypasses. There were not any more interventions we could offer. We maximized his medicines, but he still had chest pain even with minimal activity. I offered him a trial of an alternative treatment called external counter pulsation therapy.
This was a treatment not embraced by most cardiologists in this country, but after reading several favorable studies I convinced my partners to invest in this technology. Subjects are fitted with special pants that have air-inflatable circumferential compartments that inflate and deflate with each heart beat in a specially timed manner. They push blood back to the heart during diastole, when the heart is resting between pumping, and it is theorized that small vessels called collaterals build to supply better blood supply to the heart muscle and thereby reduce the angina usually manifested by chest pain. These treatments took one hour each day for seven straight weeks. His effort to endure 35 treatments paid off: He had remarkable improvement.
He enjoyed more years of stability, but in 2009 he came to the hospital short of breath and we diagnosed him with congestive heart failure. His heart had steadily deteriorated and he had developed a weak left ventricle, which is called an ischemic cardiomyopathy. We then placed an implantable cardioverter defibrillator and a biventricular pacemaker to try to prolong his life, which it did.
Over the next seven years I saw him more frequently than any patient I have ever taken care of. I was constantly adjusting his medicines to keep him out of heart failure and out of the hospital.
In 2016, during a time I was on vacation, he was in dire straits. His ejection fraction had fallen to 15 percent and he was in kidney failure. He was now 88 years old, and he was told by my partners there was little more that could be done. They consulted the Advanced Heart Failure team and he saw one of my favorite partners, Dr. Mark Jones. Even though by usual standards he was really too old to be offered this, Dr. Jones told him he might be able to buy some more time if he was put on a continuous intravenous drip of medicine to help his cardiac output. This medicine is usually only used in the hospital. In much younger patients who we are trying to keep alive until we can give them a heart transplant, we sometime will use this in a continuous drip, even as an outpatient.
When I returned from vacation I heard he had been discharged home on this constant infusion. I thought he might survive a few weeks, or at best a few more months. When I saw him the next time in the office, he told me he felt great. I could not believe the response he was having. I also thought it was quite unusual for a man of his advanced age to even want to try this, and I just had to ask what motivated him to keep going.
Knowing him as I did, I was expecting some profound intellectual answer. He told me he wanted to live because when he died, it was all over. I asked him if he had any faith. He told me he “did not believe in all that stuff.” He said an afterlife made no sense and was not logical. I shared with him that I was a believer and a Catholic. I told him I was sure that Jesus was the Son of God and that our earthly existence was just a sliver of eternity. We agreed to disagree that day and parted with our doctor-patient relationship intact.
This man celebrated life for the next 18 months, even though he was quite limited in his activities. He and his wife became experts at managing his continuous intravenous infusion and set the record for the longest functioning PIC line without an infection that I have ever seen. Our frequent office visits continued, as did his typed progress notes. We continued to spar about the existence of an afterlife, but I could not detect a change in his philosophy. I finally received a call that he had suddenly died at home at age 89.
Over the years, I had prayed for this unique man. Sometimes I would say a quick Hail Mary as I walked out of the room. I will miss him. I also have hope that we will meet again.
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