Beyond pleasantries.

He spoke in those ways that doctors like; those ways that make our job easier. Sitting all the way upright in bed, wide and relaxed smile on his face and eyes on our team and not Judge Judy blaring over his head. And I could tell that, because of this, he stole the hearts of my students and residents. That part I knew for sure because he'd stolen mine, too.

With every word, a sure nod of his head accompanied. Unsolicited compliments came from him about the bedside manner of his student doctor. She blushed quickly; it was endearing.

We were there to see him about his hospitalization for something serious. The diagnosis was one of those ones you don't wish on even an enemy and, as of this encounter in the hospital, the list of options for medical interventions had officially run out. So this, his pleasant demeanor and dancing eyes, we welcomed. We weren't contending with fear or anger or any of those other sticky things that often set up road blocks to patient care.

At least it didn't seem that way.

"What is your understanding of why you're here?" I asked. We were in a semicircle around his bed on rounds. The student caring for him on his left and me, on his right. He swung his head from side to side when speaking. Ever-inclusive of that student. Ever-pleasant which we all appreciated.

"Well," he said, "my student doctor here said it's swelling in my brain. I also saw another doctor--and he was REAL, REAL GOOD--and he say he don't think I need no more chemos or radiation. And I said, okay! Just do what you gotta do! Whatever y'all think!"

"I see."

"Yep. So now I'm getting some medicine for the swelling."

"That's right, sir. Can you tell me why you have the swelling?"

"Because of some cells, they tell me. Cells all together making some tumors. But the cells got some swelling on 'em."

"Gotcha."

And after he said that, he smiled even bigger. He turned his head to face his student doctor and nodded again. He wanted her approval.

This mostly seemed fine. But, see, I'd been doing this long enough to notice how vanilla these answers were. And I know how easy it is to get lost in pleasantries, especially during difficult discussions.

I asked a few more questions but in different words. I needed to know whether or not he realized what was going on. What it meant for someone to say "no more chemos or radiation" and exactly what that meant from a big picture perspective. So through my questions I tried my best to excavate the truth.

Was he afraid but aware?
Did he lack insight?
Was the pleasantry a mask that hid some early dementia?
Or was he simply a nice guy with a bad, bad disease?
Or worse, was it all of these?

Turns out it was. It was all of those things.

A little afraid. And seemingly aware that anything causing someone to be called to come get admitted is serious. He was right about that. His insight was poor about just how serious, though. He didn't seem to recognize that these were usually talks that open the door to ones about hospice and end-of-life care. Even though, according to the hospital chart, that REAL, REAL GOOD doctor he'd seen earlier had tried to explain this.

We proved that some of this he couldn't grab because of cognitive dysfunction. I asked his student doctor to come back and perform a mental status examination on him. The intern caring for him with that student seemed surprised by that request, but they obliged. He, too, got lost in the pleasantry and didn't see the need to question his cognitive ability. That test confirmed what had perhaps been missed before--a dementia component. Or maybe not missed but, from what I could see, not discussed. And that part would muddy up the full explanation part and likely had for some time.

So, in the end, all of this made it harder. That and the fact that there was no denying that, indeed, he was simply a nice guy with a bad, bad disease. A bad disease that he doesn't understand.

***