AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. May 2002, Volume 4, Number 5.

Perspectives

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Through the Student's Eyes: Why Are You Here?

In part II of a pre-med student's experiences with his aging grandfather, the student struggles with his strong-willed grandfather's unwillingness to comply with doctors' orders.

Dragan Gastevski

Part II of a premed student's reflection on the aging and increasing disability of his grandfather, proud founder of a Macedonian village, freedom fighter, and immigrant to America.

With the aggressive schedule of exams behind me, I enjoyed one relaxing weekend away from school at home with my family. I closed my eyes and let my tired back sink into the leather chair. The gentle hum of the television seemed to be my only companion for the moment. Suddenly, I felt a loud moan perfuse the tranquility of the room. My eyes popped open and my head quickly swiveled to my left. I saw that I had a guest.

My grandfather, Pando, was trying to get up from his slumber on the couch adjacent to me. His moaning was characteristic of a man not exactly aware of his surroundings. I had noticed that he would sleep during the day due to his inactivity. It became immediately apparent, however, that something was wrong here. Pando tried to rotate his torso so that he could sit up. I saw his hands slide across the pillows several times as his head lurched back to the pillow. Eventually, his body rose to stand erect. He leaned ahead in an attempt to get up. I began to realize that he had to go to the bathroom. He heaved his body forward while squeezing the couch cushion with his hands. During the next few attempts, I noticed that his muscles were not able to lift his body. He would, eyes squinting with pain, raise himself so close to his goal. His muscles would then give out sending him straight back down to that cursed cushion. Three attempts later, Pando was on his feet, staggering around the couch. His knees wobbled left and right with each placement of his cane. I listened to that characteristic tap-tap-tap, not knowing whether he would make it in time.

Ten years ago, this would have been no problem for Pando. When I was a child, I remember my mighty grandfather coming home from work exhausted. He only needed one look at my face to convince him to toss his bag through the door and set off on a mission to get me some of my favorite restaurant food. Together, we were like one. We would go on field trips to museums and the park. Whenever I would tire, he would grab me with his enormous arms and hurl me up to his shoulders for the rest of the trip. Yes, this man would laugh in the face of pain, having spent 2 years in a Nazi death camp in his youth. The medical difficulties he was experiencing 10 years ago were not entirely unwelcome reminders of the excruciating pain and extreme suffering he experienced in his early years of manhood.

Today my grandfather suffers from immense pain associated with arthritis, diabetes, and myriad related diseases. His doctors prescribe certain medications and treatments knowing that, though they are difficult today, they will have a large positive impact on his future. After Pando's toe amputation surgery, his doctor ordered home physical therapy. Pando told the doctor that he understood what was asked of him. To my eyes, it appears that the doctor must have ordered sleep! Why is it that Pando does not follow what the doctor has ordered? Whenever I am home, he takes out his green exercise rubber band, attaches it to the appropriate foot, and begins his exercise. "See," he says in his broken English, "I work really hard!" I watch and congratulate him on his efforts, thinking that this is the way he lives everyday of his life, regardless of my presence. As I walk away from "his couch" and proceed into the kitchen, I notice his efforts diminishing. Pretending to take no notice, I continue building my sandwich. I put the pickle jar back into the refrigerator and close the door, uncovering a completely different scene in the living room: My grandfather is facing away from me but obviously sleeping. He has dozed off, letting his feet rest on the floor, rubber band and all.

At the next office visit, the doctor asks, "Pando, are you doing your exercises?" "Yes," he says, "My grandson sees me!" The effort to back up his statement is futile; the doctor sees there is negative progress in the muscular development of his thighs. "You know, Pando, you won't be able to get around the house unless you do these exercises," prompts the doctor. "Ya," Pando immediately replies with an air of guilt in his eyes, "I get roun' no problem in da hous." The doctor forces a smile but realizes that his attempts to convince Pando to exercise are also futile. He goes through the routine one more time, mechanically emphasizing the steps of each exercise, and sends us home. I leave with Pando feeling even guiltier than he; I know he will do the same thing he always does.

It is one thing to order a 5-year-old to pick up his toys, and another thing to order this aging head of a dynasty to do his exercises. The 5-year-old, however, will ignore your orders for the same reason the grandfather does: just because he doesn't want to do the task. If something does not bring pleasure to a person's life, why should he do it? Doctors and family will argue that it is the greater good that is desired. Temporary pain and discomfort caused by exercise and other prescriptions will eventually lead to a higher overall level of happiness. This may be a valid argument for the 5-year-old, but in truth, it is not valid for Pando. Perhaps the pleasure derived from much needed relaxation is far greater than the pleasure he would reach after doing many grueling exercises. On the other hand, it is also difficult to sit in my leather chair and watch my grandfather live the remaining years of his life, not knowing whether he will make it to the bathroom. Pando once told me an old Macedonian anecdote. "Dragan," he said in his native tongue, "the old are like children. We think and act as if we are going backwards through the stages of maturity." How very true, I immediately thought.

Non-compliance is a serious issue that can be due to difficulties in language, intelligence, or mental disposition. In this case, Pando, with his pre-medical student interpreter, has no reason except his mental state to not comply with the doctor's orders. And unfortunately, some doctors will sever the relationship if visits don't progress toward results. In one case, Pando's endocrinologist asked him how the prescribed insulin was working for him. My grandfather replied, "I don' take insulin. I take pills." The specialist bluntly replied, "Then why are you here? What more can I do for you if you don't do what I tell you." Pando now sees a different endocrinologist. It is fair to say that billing Medicare for appointments that yield nothing but small talk seems nonsensical. Interpreters are provided to overcome language difficulties, and guardians are appointed for those with less than the required intelligence. But what can doctors do for those patients that just won't follow orders for whatever reason they see fit? After all, the patient-physician relationship hinges on the patient's desire to do what is necessary in order to be helped.

Part I of Dragan Gastevski's reflection on his grandfather appeared in Virtual Mentor in March 2002.

Dragan Gastevski is a biology major with a psychology and neuroscience minor at Loyola University. He plans to enter medical school upon graduation this year. Dragan has a strong interest in medical ethics and has worked as a public health counselor over the past year.

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