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| The New England Journal of Medicine, December 12, 2019 |
Adjö — My Patient’s Prolonged Good-Bye
List of authors.
- Uchenna Ikediobi, M.D., M.P.H.
"Do you know how to say au revoir in Swedish?”
His eyes light up like miniature moons, cataracts shimmering with childish joy. His lips pull back into a smile, revealing teeth browned and loosened from their foundation. His mind, having churned thought after thought for 95 years, can’t keep up now, so he asks me this same question at every clinic visit. I smile and pretend I’m answering for the first time. Every time.
“No. How do you say it in Swedish?”
Over the years, his visits to the clinic have become less about the monotony of restaging his medical diagnoses. We don’t spend as much time reviewing his chart. We feel a certain lack of direction in managing the care of a patient who has surpassed the average life expectancy. In the race of life, he now runs alone. His days are filled with the deafening silence of an extended existence, a contrast with a past filled with jubilant noise — the sounds of a baby’s cry, his wife’s voice, water clearing his course as he swam. Crowds would gather to watch him compete in swim meets in college, their cheers buoying his fishlike frame. But the muscular arms I imagine he once relied on to power down the length of an Olympic-size pool now hang by his sides, devoid of purpose.
As I listen to him, I notice that his memories begin from afar, as if on the horizon. They stop halfway to the shore where he now stands, in the present moment. He recalls the days on the battlefield during World War II: arms tight around his rifle, orders from his superior officer echoing in his head, his hardened gaze focused on the enemy. He describes his cherubic Swedish mother tucking sleeves of Knäckebröd in his pocket — an homage to his heritage — as she ushers him to grammar school, the scent of the crispy bread still fresh in his mind. But he struggles to recall details of a conversation we had just 10 minutes ago. His distant memories are as clear as the waters he once waded, yet they keep him trapped in a world that no longer exists.
As we converse, I can see again that he has difficulty accepting his loneliness. His wife has been gone for more than 10 years. He carries a weathered photo of her in a folded brown wallet, the edges of the photo missing as if consumed by moths while the subject remains timeless and whole. His eyes glisten and his voice cracks as he tells me how much he still misses her laugh and her company.
I find myself thinking about men his age I knew when I was growing up in Nigeria. In Igbo culture, these men are called elders. On celebratory occasions, they would be arrayed in elaborate traditional attire, native jewels and beads decorating their wrists and necks as they stood stoic, strong, and tall, while “talking drums” reverberated in the background. I recall how these men, whose exact ages were unknown but presumed to be near 100, were revered and surrounded by members of their community — they were never alone. I marvel at how different my patient’s life is from those of the Igbo elders. I wonder fleetingly what effect their adornments would have on the man withering before me.
I have an instinct to reach out and touch his hand — the hand that still grips the weathered photo but now rattles frightfully with a fine tremor.
I lack the words to ameliorate the painful silence that surrounds him, centers him in its grasp, consumes him. But I am aware of the reprieve offered by these clinic visits, when he can share his jokes and memories and feel the attention of an audience, even an audience of one. So I listen patiently. I don’t hurry him along as his mind stutters to retrieve catalogues of experiences from his past. I try not to glance at the time on my computer screen, afraid that 30 minutes have bled into an hour. I’m not feverishly writing notes to keep up with the torrent of his stories, which lack clinical relevance but are begging to be heard. Often, I have to repeat myself — louder each time — willing my words to have as much meaning for him as his have for me. And each time, we recreate the foundation of a friendship that fails to plant roots in his weary mind.
Growing up in Nigeria, I was surrounded by the immediacy of death, by the possibility of truncated lives leaving potential unfulfilled. Days were spent balancing the pursuit of purpose and avoidance of early death, and people often turned to prayer as a mediator. People whose lives stretched out far in the distance, like a thread pulled free from its spool, were celebrated and honored. Because of their age, they were often viewed as reservoirs of wisdom and guidance for others seeking direction. I had therefore always seen it as an honor to live a long life, never contemplating the opposite perspective, until I met my 95-year-old patient. Whereas in my culture, reaching that age was praiseworthy, for my patient it was a curse.
As our visit comes to an end, he tucks his wife’s photo into the lip of his wallet and picks up his bag; I leave my scattered musings about life’s purpose uncollected. He continues to share stories, as though they’ve broken free from the dam of his subconscious. He asks me again where I am from, and I answer him again, as if for the first time. As if performing a play in which he knows his part by heart, he tells me again that he once had a friend from Nigeria. But this friend, like all the others, has since passed away. And our visit is once more punctuated by the theme of loneliness.
As he reaches for the door handle, no doubt feeling the pressure of my guilty need to see the next patient, he turns around and asks me, “Do you know how to say au revoir in Swedish?”
By this time, I do. But I’ve learned to play my part.
“No,” I say. “How do you say it in Swedish?”
