Sequence of Ephemeral Diagnoses

“If remaining life can be shortened and made insufferable with words, can it not just as easily be shortened and insufferable by silence?”[1]. 

Mr.OM (not actual initials) was an 84-year-old male whose wife passed away in her sleep.  He and his wife were healthy, active, cared for each other and loved outdoors. They were financially sound. Mr. OM was grateful that his wife died in her own bed next to him without the process of dying. He planned her funeral meticulously and was happy to see his relatives and friend coming in for the funeral. They had two daughters, caring, independent, and successful. Till the funeral, Mr. OM was occupied with the arrangements; he was alright. Few days after the funeral, his daughters returned to their home, satisfied that their father was doing so well. 

In 1969, Elizabeth Kubler-Ross identified five stages of grief, in her book “On Death and Dying “namely denial, anger, bargain, depression and acceptance. It is of note that number of stages and their sequence is quite variable [2]. Apparently, Mr. OM was in denial all this time and acted normally in presence of his company. When everyone left, he felt lonely, and he became angry at his situation. He could not express his anger, so he internalized it and became stoic. 

Dr. Christian Bernard decided to use Chimpanzee’s heart for heart transplant. He bought two male chimps from a primate colony in Holland. They lived next to each other in separate cages for several months. To use one chimp as a donor, he was premedicated for sleep in his cage. Sensing his bleak future, the chimp chattered and cried incessantly. Finally, anesthetic medication took effect and chimp fell asleep. As soon as the attendants transferred the body to OR for removal of the heart, the other chimp cried, did not eat or drink for several days. He showed no sign of recovery until he was placed in another primate colony where he found a mate in female chimpanzee and had a son.  Seeing so much distress in a companion of few months, Dr. Bernard did not use Chimpanzee’s heart for the human transplant [3].

Hearing from the neighbors about his condition, family called the doctor’s office who diligently arranged for home health nurse. She came and took the vitals meticulously and made sure that meals on wheels were delivered to him. No one knows when anger changed in depression. He stopped getting up from his bed. Home health nurse suggested adult day care, but it was not easy to find a reliable person to drive him back and forth. Finding no other alternative, his daughters asked the nursing home van to pick him up.  He looked at the door to say goodbye but to whom? Both of his daughters were compassionate, independent, and successful. They could spend money for their father but could not give time. Both daughters decided to put their father in a nursing home without asking his opinion. He had no significant disease. Just living in the nursing home required to maintain a schedule, he felt he was in jail. He had lost all his freedom. Gradually, he became lethargic and unable to sleep. It made him unstable on his feet during the daytime. Neurologist saw him and found to have strength of 3/5 in both legs, diagnosed as paraparesis, wheelchair was ordered, initially manual which was promptly upgraded by his daughters to motorized. That did bring smile to his dry lips at least for once. He stopped eating. Work force in nursing home had been stretched so thin that no one could feed him. He was not drinking enough water as well. One day when routine labs started to drift towards renal failure, doctor at nursing home suggested gastrostomy tube for nutrition and hydration. Elder daughter was available to give consent over the phone and patient received feeding tube the same day. Realizing how helpless he was, his depression deepened. 

Just few months ago, he was contributing member of his community; he was driving, carrying groceries, paying all his bills and maintain his house without seeking help from others. Now he was stuck in bed and could not go to attend the calls of the nature and got indwelling Foley’s catheter and diaper. He cried with tears and stopped responding to his name. Staff considered him to be hard of hearing. Probably he would have died in the nursing home under distress and most unfortunate circumstances except for a sharp young audiologist who was called for hearing machines for Mr. OM. He stopped himself from falling from chair when not only Mr. OM could hear everything, but he also had witty answers as well in clear speech. After speaking to his fellow medical caregivers, he was able to get rid of Foley’s catheter and temporarily stop gastrostomy tube feedings. Swallowing study ruled out any aspiration, it was normal. On patient’s request, a psychiatrist assessed and treated for situational depression and came out of its n flying colors. Now it was time for him to leave nursing home but where should he go?  His home was for auction. With his daughter’s prompt actions, procedure for auction was stopped and Mr. OM could return to his home. His friends, neighbors and relatives were happy to see him back in good spirits and health. When asked what was wrong with him? He smiled and said he had “Placement syndrome”.

1. Katz J (1984) The Silent World of Doctor and Patient. APA PsycNet 4: 626-628.
2. Elizabeth Kubler-Ross (1969) On Death and Dying. 38-137.
3. Marshall Kapp B (1980) Good Life Good Death A Doctor’s Case for Euthanasia and Suicide by Christiaan Bernard. Cambridge core 9: 60-61.