I served my internship in Los Angeles in 1973, a time when the decision to start a patient on dialysis was made by a hospital committee — some called it a death committee. The kidney care act had passed the U.S. Congress in 1972, but was not yet in effect. My patient was in her late 70’s. She had renal failure but she was not offered long-term dialysis. In those years, it was a common temporizing method to admit patients to the hospital for a brief course of peritoneal dialysis.
Every two weeks or so, I performed a minor surgical procedure to place a temporary catheter in her peritoneum and treated her with peritoneal dialysis for 3-4 days.
With this regimen she continued stable between September of 1973 and April of 1974. Her will to live was strong, and she bore suffering with stoicism. She had a sweet sense of humor, and she sustained me when I felt I was putting her through too much pain. Then her son died suddenly in a hunting accident. Within days of his funeral she was admitted to the hospital through the emergency room. Fortunately I was on call (or maybe she knew my call schedule). She stayed alive long enough for me to perform an admission workup, and to determine that she was medically stable. She told me of her son’s death. Then she slipped quietly away: she was dead when the nurse checked on her 10 minutes later.
I remember walking into her room at dusk. Her body had been removed, and the bed was freshly made, clean and empty. I thought to myself, “Mrs. Archie is no longer here?” as if I were asking myself a question. I longed for her when I looked out her window towards the distant San Bernardinos. The sun was gone. Together with a deep sense of calm, the pinks, grays and blues of sky and mountains became emblazoned in my memory. That an individual might choose the moment of her own death was a new idea for a young doctor. I believe my patient gave me a gift, which grew more lucid with the passage of time. My sense of her presence, together with this twilight image, remains clear in my mind — a sort of career touchstone, and the first of many lessons about the privilege of tending the dying.