A exemplary teacher at the end of life

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It wasn’t easy becoming a physician. But I didn’t do it by myself. I’ve had help and guidance all along from well educated people and teachers who spent their lives helping others advance. Sometimes a teacher comes into your life when you aren’t looking for one or even have the time to think about one. Recently a partner had some time off so I saw one of her patients in her absence. I was behind and rushed, as usual, when I stepped into the exam room and introduced myself to Sylvester LaDuke.

I had reviewed his records enough to know that Sylvester had metastatic (spreading) cancer, but his records were sketchy and I didn’t know much beyond that. A nurse commented that she thought he was in denial about his prognosis before I went in, and that’s the expectation I had as I walked into the room.

I expected to see a man desperately holding out for a cure and a miracle. Instead, I met a smiling man who welcomed me into the room. His eyes were bright and clear, his smile was sincere and real. In spite of that, he was pale, gaunt and clearly sick. He had dark circles under his eyes and his words came in short, labored sentences. His belly was huge, even under his baggy shirt. He was clearly short of breath just sitting on the exam table.

“I would like to know if my cancer is worse,” he said. “Last year I was told I had five months to live. This year I’m going to plant tomatoes.”

He had no illusions about his cancer and his prognosis. He knew this was a bad cancer and that it was spreading.

What the records showed

I went through his records again and found a CT scan report from 6 months ago. This was from a different medical system and the report concluded with “interval worsening” since his last study, with spread of cancer to multiple areas of his liver, into his abdominal wall muscles and into the mesenteric area (where the intestines attach internally).

His cancer was a GIST (gastrointestinal stromal tumor), which is a rare cancer. It can either be slow growing or very aggressive.

Unfortunately, Sylvester had a very bad cancer that spread rapidly. He had already asked for DNR (do not resuscitate) status, and this was in his records. There wasn’t much to do at this point except to make sure he was comfortable and didn’t suffer.

On examination, Sylvester’s lungs sounded clear in the upper portions, but decreased in the lower right side. He lifted his shirt and I could see the massive tumor under the skin on the entire right side of his belly. It was tented up at an unnatural angle and as hard as wood. As I felt around the edges of the tumor, I could feel that it went deep inside his abdomen, and I could feel other smaller tumors. Sometimes diseases that involve the liver cause ascites, which is fluid collecting inside the abdominal cavity. I could not find any ascites on the basis of that exam, but hoped for it as draining could help his breathing.

A chest x-ray showed part of a rib eaten away and a mass inside his chest. He accepted those results without complaint. Through all of this, he smiled and planned his garden.

A social worker accompanied Sylvester. I asked if he was always like that.

“Short of breath?” she asked.

“No. Is he always this positive?

“Always.”

The height of courage

I knew as soon as I met Sylvester that he had a gift. Not many could look death in the eye with his grace and dignity. I asked him if he would consent to go to the Medical School with me if I could set up a day so medical students could meet him and learn from him. Not just from a cancer standpoint, but from a spiritual standpoint and a lesson in the beauty of life. We can all learn that lesson. He agreed immediately.

The following week was spring break at the Medical School. The week after that the medical students would stay with doctors in rural communities for what’s known as preceptorships. The earliest Sylvester could visit the Medical School was three weeks away. I arranged for the visit; he was happy for the opportunity.

Early the next week I got a call from the social worker. Sylvester lived more than 100 miles from the reservation, and usually came to our clinic for prescription drugs. The distance and getting rides created a hardship for Sylvester.

I arranged for Sylvester to have a procedure to drain fluid from his belly under ultrasound. Unfortunately, there was no fluid present to drain. I then ordered a CT scan of his chest, abdomen and pelvis to see if the cancer was causing his shortness of breath. His kidney function tests were abnormal. He couldn’t tolerate the contrast needed for the scan, so he didn’t get it. “Contrast” is the dye that enhances the CT scan to show internal organs and tumors. Contrast is filtered out through the kidneys and can damage kidneys that aren’t working properly.

Sylvester rose at 4 a.m. that morning, traveled over 200 miles and wasted one of his few precious days for nothing.

Later in the week, I got a call from a hospice nurse. Hospice is end of life care and is usually done in the last six months of life. This is wonderful care and allows those with terminal illness to spend their remaining time at home with comfort and dignity. Sylvester wasn’t any worse, but had finally accepted hospice care to ease his final days.

The next week I got a call from a doctor in the hospital in the town where Sylvester lived. He had been admitted to their hospital with a fever, but the source of the fever could not be found. Sylvester became increasingly short of breath, confused and less and less responsive.

I talked with the social worker the week after my only visit with Sylvester. She said that on the drive home, Sylvester was excited to be going to the medical school.

“I’m going to teach doctors!” he said. “I always worried that I would be forgotten. Now I get to have people remember who I was.”

The social worker told me that sometimes Sylvester would play a harmonica for her in the car.

“It was quiet and haunting,” she said. “Sometimes I could barely hear it. It was beautiful.”

What Sylvester taught

As I write this, Sylvester is in the hospital and is not expected to survive the night. He is not responsive and has family present. I wanted to be there and to hold his hand, but I’m on call and I can’t leave. I wanted to thank him for teaching me the beauty of life and making me realize that the things we take for granted won’t always be there. I wanted to apologize for wasting one of his last days trying to get tests. I wanted to let him know that I’ll plant the tomatoes this year. I wanted him to know that he will be remembered.

Always. He will be some small part of whatever I do from now on.

I wanted to say I was sorry for taking so long to get him set up to teach the medical students. His schedule was more important than our schedule.

I wanted to thank him personally and publicly for what he taught.

I can say this now.

Thank you, Sylvester


Dr. Arne Vainio can be reached at
a-vainio@hotmail.com

Sylvester LaDuke lived from Feb. 14, 1942 until April 9, 2007.

Editor’s note: Dr. Arne Vainio is a member of the Mille Lacs Band of Ojibwe, and is employed as a physician with the Fond du Lac Reservation.

In future issues of this paper, Dr. Vainio will write about his role as healer and teacher in a way that makes sense of complicated medical issues.

He wrote that his essays “will include what I see as a physician and how that relates to and touches me. Even though I’m a physician, my story is not all that different from stories I see every day. My family history is the family history of Native families everywhere.”

In this story about Sylvester LaDuke, Dr. Vainio shows his urgency in attempting to extend the life of a wise, good-hearted man.