 Good afternoon, I'm delighted to welcome you back to our third panel. This panel will focus on end-of-life issues. It's my pleasure now to introduce the moderator of this panel, and that is Dr. Susan Toll. Susan completed the McLean Fellowship in 1988-89, and when she finished, she went on to become the founding director of the Oregon Health and Science University Center for Ethics in Health Care, which she has directed since 1989. Dr. Toll was the youngest person ever appointed as a professor at Oregon Health and Science University. In 2014, Dr. Toll received the McLean Prize for outstanding work throughout a career, but in particular for developing the Pulse System, the Pulse System Physicians Orders on Life-Sustaining Therapy, and for improving end-of-life care throughout the United States. The Pulse model has now been adopted by more than 40 states, I think about 45 states, in the U.S. Today, Dr. Toll will moderate the presentations on end-of-life issues and will herself give a talk entitled Pulse in Changing Times, New Developments and Challenges for us all. Please join me in giving a warm welcome to Susan and Toll. It's a pleasure to be here, and it's wonderful, and congratulations to every one of you on this being the 30th McLean Conference. Our first panelist is someone who was one of Mark's very earliest fellows in the 1980s, and who every year helps all of us think about how we bring the humanities and the work that we do to truly connecting with our patients. It's so fitting to have David Shiedemeyer be the person who, after lunch, brings us back together and helps us do the work we do in a deep and rich way. Dr. Shiedemeyer is a palliative care specialist who has spent his professional career in Wisconsin. He went to medical school there, he did his residency there, and he has written three books, and with them one was with John Lapuma about ethical consultation, a practical guide. He is very active in the Medical Humanities Program at the Medical College of Wisconsin. Many of us remember some of his prior presentations here as an avid harmonica player, and he is giving us a talk today with music that brings us a connection under the title, Tomorrow is a Long Time. Please join me in welcoming David Shiedemeyer. Walter Meltzer, age 86, has been my patient for more than 20 years. We actually met through his wife, Dottie. I treated Dottie for several years before I met Walter, and Walter and I agree about most things. For example, after his wife died, we had Walter over for supper one night. I knew somehow that he would share my taste for tapioca pudding, and he did. He grew up near Watertown in the southern Kettle Moraine of Wisconsin, and as a boy I must admit he was a bit of a show-off. That's how he lost the distal half of his right ring finger. One thing that's easy to ask patients is, how did you lose that? He was trying to impress a girl by swinging from a branch, and his class ring caught on a stub. But his hands worked well. He made his own dining room chairs. The duck decoys he carved 50 years ago now sell for thousands of dollars. An instinctive and talented artist, he worked designing dioramas for the museum. He crafted each scene in the diorama with paper, paint, foam, molds, hides, dry vegetation, metal, plastics, glue, and clay. His exhibit of a Native American buffalo hunt on horseback still remains a main attraction to this day. If you've ever been to the Milwaukee Public Museum, you'll see that's a front and center display. Walter traveled widely learning about nature, collecting specimens in places like Guatemala and Botswana. His first love was walking in the fields, right around Wisconsin, watching birds, collecting arrowheads. One time after I made a house call, he quietly gave me one of these arrowheads. This arrowhead actually was from the Red Ochre culture, and that is about a 3,000-year-old arrowhead. It's orange-flect, lancelate-shaped, stemmed, it's a point of great beauty, and it's just like something Walter himself would make. Walter's medical problems are colon cancer, history of aortic aneurysm repair, below-the-knee amputation of his right leg, phantom pain in the stump, emphysema, CHF, prostate cancer treated by watchful waiting, depression. Walter is not a religious man. On the other hand, God was his wife's favorite topic of discussion whenever I saw her in the clinic. After Walter became my patient, Dottie often asked me to speak with him about God. She considered it part of his medical treatment. She thought the cause of his depression was actually his lack of faith, his lack of hope, his lack of love, his lack of joy, all from being without God. But I'd been silent about this with him. However, on the night before his colon cancer surgery, in honor of her, I gather up my courage. Where are you with God, Walter? I ask. Not that it's any of my business. But if your wife were alive, I know she'd want me to ask you. She always did. Well, doctor, she would. I know it. But you know all the things in the Bible. I just can't believe them. I really can't. I think we're no better than earthworms. We're just in control right now. When we die, we go back to nature. And I'm so sorry when I see what we're doing to the earth. I feel for the earth. I really do. I can understand that, Walter, I say. What I meant was not that I agreed with them, but that I could understand why a man who knows the difference between a moth and a butterfly, an antler and a horn, a hawk and a falcon, this kind of person would be happy just being part of the earth. He has such a high regard for it, after all. But Walter is also an anxious man, very afraid of dying, desperately afraid that the tumor will prove unresectable. Doctor, I know it has to happen. I just don't want to suffer with cancer. I have some friends die with it, they just waste away. It's awful, he says. I take this as my cue to examine him. He has a face like a cooper's hawk. Piercing eyes, a sharp nose, a big gray mustache, a slightly twisted smile. He speaks slowly. He sits up in bed rubbing the stump of his amputated leg in obvious pain. His tumor proves receptable. He accepts this good luck with visible relief. But if Daddy were alive, she would have told him, it wasn't luck, it was a miracle. It wasn't luck, it was amazing grace. He was lost, but now is found. Well, several months later, Walter is found by his daughter Helena sitting in his chair holding a loaded revolver. Helena, who teaches hunter safety courses, it's Wisconsin. She unloads his gun, but she doesn't take it away from him. Walter, who has always called me frequently with any new symptoms, aches or pains, now begins calling more often. Sometimes several times a day complaining, he's not getting enough pain medication. My son even has a minor bike accident rushing through the snow to tell me a patient in terrible pain is called our home, and it's just Walter with his usual pain. But I can picture him suffering, rubbing his leg, so I ratchet up his meds using all my tricks. A pound of morphine, a half pound of tricyclics, patches and creams, roots and shoots. Even so, when I next visit him at home, he asks me to pray for his death. I know how he feels about prayer and death for that matter, so I can't tell if he's kidding. I tell him that only priests, ministers and rabbis can pray at that high spiritual level. I'm just a doctor and I can only pray for people to die slowly. This gets a small smile from him, so I know he is kidding. So I tell him that his wife wouldn't think he's ready to die until he's made his peace with God. He grunts and says, huh, don't wait for that. But again, he gives me a small smile, so we turn to talk of the cooper hawks who are eating his mourning doves at the feeder. On exam, he's not in pain for a change. The meds are working. As I'm leaving, walking out in the cold, I look back as I close the door. He is alone in a halo of light, sitting in his reading chair, rubbing his leg from force of habit. If today was not an endless highway, if tonight was not a crooked trail, if tomorrow wasn't such a long time, then lonesome would be nothing to you at all. It's six o'clock on a Friday evening, six months later, and Walter calls me with symptoms of acute urinary retention. I meet him in the emergency department, and I try to insert a foley, and the catheter goes in first easily, then with great difficulty, then it just stops. No urine at all. Walter, I say, I think I'm caught on the prostate. I'm going to have urology come and pass the catheter the rest of the way. I'm afraid to move. I'm afraid I'll lose the catheter position. Sometimes after a traumatic attempt at a foley insertion, the urethra becomes so swollen, it's virtually impossible to insert the catheter at all. At least that's what I seem to remember. I become determined not to move for Walter's sake. I have the nurse put a sheet over my hands and paid urology. Walter's penis is as soft, tiny and flexible as a half-eaten piece of string cheese. The foley feels like a little rubber hose inside the string cheese. I really do wonder what we will talk about. I was out in the garden, I say, you know, I'm trying to plant gourds this year. I remember you telling me, Walter, that you can make things like drums and birdhouses out of gourds. Walter nods. You can. The different types of mold and fungi make them turn beautiful colors, red and black spots, but you've got to dry them out well. You've got to kill the mold and you've got to seal them with shellac. This led to a long discussion of shellac and other wood finishes. Pretty soon, 30 minutes later, the urologist arrives. I expect him to use an ultrasound for a small scope and skillfully advance the catheter around the bulge caused by this huge prostate, but instead he pulls it back just an inch. A golden stream of urine twists down into the bag. Walter's bladder pain begins to resolve as the bag fills. The foley was stuck in a bladder diverticulum. Now I recall that Walter's CT scan for his colon cancer is an unusually large bladder diverticulum as an incidental finding. So the foley was stuck in a blind alley inside the bladder all the time. I could have pulled it back an inch myself. For his part, Walter's just relieved. He doesn't care that it took a half hour. The urine is still streaming down in the bag. You know, there's beauty in that silver streaming river. There's beauty in that sunrise in the sky. But none of these and nothing else can match the beauty that I remember in my true lover's eyes. Walter lived a few more years. He didn't shoot himself or overdose. He just ended up dying of COPD from all that smoking when he was making those dioramas. Ended up dying in the hospital up on the fifth floor with just me there that morning. Ended up resting in bed not with Dotty next to him but with me in my white coat in the chair next to him holding his hand. Ended up with me ordering enough morphine so that even an anxious narcotic habituated hypochondriac could not hear his heart as softly pounded. Could not know that he was returning to the ground that he both feared and loved. In the end, the doctor and the lover have this in common. Only they can help us rest in our beds at the time of our greatest distress. Only they know of our worst weaknesses and are willing to cover them up. To palliate them. Just like a lover, a doctor's ministrations and a doctor's medications can make tomorrow not such a long time. Can smooth that crooked trail over the years. Can make lonesome mean nothing to you at all. Well, some of you may not believe this doctor-patient love story. Others of you might not even approve of a doctor getting this close to a patient. Don't get me wrong, a lot of my patients have forgotten me and I sure have forgotten them. But let me go on record to say that there is room in every doctor's heart for someone like Walter. Or at least I think there should be. And in terms of why, well, I have two reasons right here. Here's a mandolin that I made with my own hands out of a garden cord inspired by Walter. And in honor of him, it's complete with the kind of shellac that he would have used. Oh, and somewhere here, here's my arrowhead. Questions? Questions? Yes, John. Yes. And I think the question is what allows a doctor to find that kind of space for a patient? And maybe a corollary to that would be, you know, is it even right to find that kind of a space for a patient? But, you know, a doctor and a lover also share that they cannot always control who they will be close to. And I think that's the thing that came up. I first met Walter. He had such a slow way of speaking. I thought he was a Wyoming rancher. I just thought he was the coolest guy. I couldn't help it. So I'd say you can't help it. We're not talking about, you know, wrong boundaries here. I think we're talking about friendship. Whether it's love or not depends on what you think love is. Friendship. And I think there's room for some of these folks and some of these relationships in our lives as doctors. I know Mark has, and many of us that have been practicing a long time, we have patients that are favorites. And be they, it's not about, it's the grace that the patients have themselves. It's not necessarily about who they are. I've just reminded some of my patients, I have a 95-year-old woman and I said, well, tell me about your children. And she said, well, I have a son. And I said, tell me about him. And he said, oh, he'll never amount to anything. He's retired. So our patients are, it's not about their, you know, it's a relationship. And of course, Walter, you know, we never did get him the deathbed conversion that his wife so desired. But I figured they were married 60 years. She could have told them. But she really thought, you see, that God was part of his health and that my job was not necessarily to convert him to something, but to mention he should get, this is what he needed for himself via his wife. I mean, don't patients say you've got to make somebody quit smoking. You've got to, any other questions? All right, thank you so much.