To Comfort, Always

By her own admission, Sophie was an anxious person. For many years, she required intermittent benzodiazepines to control her symptoms. She had a soft but clearly audible stridor on the inspiration of every breath, which became more pronounced when her anxiety increased. This was balanced with a disarming smile and endearing formality; in spite of my repeated requests for her to call me by my first name, she invariably referred to me as “Doctor” and it began every question she asked.

“Doctor, what is making me sick?”

“I don’t know,” I replied, “but I’m doing everything I can to figure it out.”

Sophie looked at me, unsatisfied with my response. Her face hardened and she asked me a more difficult question.

“Doctor, am I going to die?”

“I don’t think so,” I said. This was even more unsatisfactory.

“Doctor, you don’t think so?” Her stridor grew louder.

I was careful: “I’m not exactly certain what is causing you to have such low blood pressures when you stand.”

Sophie’s expression was unchanged; I clearly had not given her the answer she was looking for. She repeated herself.

“Doctor, am I going to die?”

She said this sitting bolt upright, looking directly into my eyes as if to suggest there was bad news that I was simply not telling her.

I thought for a moment, wanting to provide some certainty in the clinical swamp of shoulder-shrugging and hand-waving in which we were mired.

“No,” I said, “of course not.”

She smiled, sank back into bed, and wished me good-day. Her stridor subsided.

Sophie was a thin woman in her middle 60s. She was born in Italy and immigrated to the United Sates with her siblings many years ago. She still carried a slight accent. Sophie and her husband David ran a small sandwich shop in a charming New England town. David sat dutifully by her bedside, having temporarily closed the business. Life, his or hers, could not continue until Sophie’s health was better. Her talk of death made him fidget as he looked away.

Sophie was a true medical mystery, almost unbelievably orthostatic—her blood pressure fluctuated wildly, from very high values laying flat to those barely measurable standing up. Her orthostasis became progressively worse, and Sophie was essentially bedbound by the time she was admitted to my service. She underwent innumerable tests and was seen by multiple consultants, with no definitive explanation for her condition. Eventually she was able to walk short distances and was discharged home, with very close supervision from her family, visiting nurses, physical therapists, and her outpatient physicians.

I was the hospitalist caring for Sophie for the entirety of her two-month hospitalization. She continued to ask regularly whether she would die, each time with a characteristic unwavering matter-of-factness, as if she knew a grim prognosis was being kept from her. I continued to give her the same answer, “No”, principally because she was not explicitly ‘dying.’ I had no explanation for her orthostasis, but she’d had a battery of negative tests, and her blood pressures were improving with treatment. Her many symptoms—stomach pain, dysuria, chest pain, nausea, and seemingly countless others—fueled her perpetual concern and amplified her stridor. Reassurance was the mainstay of my treatment, more potent than the medications and compression stockings combined. With each installment of my comfort and reassurance, her tension and stridor ebbed.

One particular day, with her blood pressures better and her multiple symptoms less prominent, Sophie asked me a different question.

“Doctor, my daughter is getting married this summer. Do you think I’ll make it until then?” She was nodding, hopeful. I could barely hear the stridor. Sophie was visibly searching for a particular response, and I was more than happy to oblige.

“Make it?” I embellished—she was improving, after all: “You and David will be walking her down the aisle!”

She smiled, lay back in bed, and picked up the phone to order lunch.

Sophie died within two months of hospital discharge. She did not make it to her daughter’s wedding. Her death, a cardiac arrest by all accounts, was as inexplicable as her orthostasis. She spent a few days in the ICU before David could bring himself to withdraw care. Upon hearing the news, I sat down immediately, paralyzed. I was heartbroken for my patient, her husband, her daughter. I also felt guilt: had I lied to her? Countless times Sophie had asked if she was going to die, and I had reassured her every time that she would not.

I learned the value of reassurance during my first year of medical school from my preceptor, an amiable pediatrician. He excelled at it; with the comfort he provided, children and parents routinely looked at him with a combination of relief and admiration. I did too—he embodied what doctoring was supposed to be. At the end of the day, we’d sit at his desk, discussing patients and the power of reassurance as a therapeutic tool. With Sophie’s death, I had lost that power. I doubted I could ever really reassure anyone again.

As the months passed, I remained unsettled. I could still hear Sophie, her stridor at maximum pitch, echoing the same question in my mind. Doctor, am I going to die? I could not escape the image of David and his daughter at her wedding, staring at Sophie’s empty seat. My interactions with my patients were changing, as I found myself giving progressively noncommittal responses to their questions.

I had to do something. I began to write about Sophie. I sent an unfinished draft of this very piece to her primary care physician, a friend. His response was unexpected.

“I saw David in the office today,” he told me. “I mentioned that you’ve written a piece about Sophie. He’d like to read it.”

I jumped at the chance to reconnect with David. I e-mailed the piece to him immediately.

No response, and more months passed.

At 9 p.m. on a quiet Friday night alone, my wife and children with my in-laws, my pager beeped. It was David.

“I hope you don’t mind the intrusion,” he said, “but I’d really like to talk.”

“Of course,” I told him. I had been eager to hear from him.

“I’m just so lonely. It’s very hard without her. I can’t bring myself to sleep in our bed. I wake up in the middle of the night, and I think she is still alive. I get confused to find her not here.”

We spoke further. David related the circumstances of Sophie’s cardiac arrest: horrifying. The decision to withdraw care: impossible. The funeral: difficult. Their daughter’s wedding: redemptive. He has re-opened the sandwich shop. He talks to his daughter every day. David is getting by, but he needs something. Comfort. Reassurance. And he is asking me.

“You really listened to her. She appreciated that. Sophie really liked you. I was wondering…” His voice trailed off and there was a long pause. “Can we talk from time to time? I’d like that.”

“So would I,” I said. “So would I.”

I hung up, sat back on my couch and cried. The doubts and fears plaguing me for months evaporated. I pictured Sophie, smiling, her stridor gone. I again recalled the office of my pediatrician mentor, this time elevating my gaze to a plaque hanging above his desk. Its slogan is one encountered by many of us along our paths in medicine, and at that moment it had renewed meaning for me:

I am a Physician.

To cure, sometimes.

To relieve, often.

To comfort, always.

I can only hope that Sophie, were she alive today, would agree.