With a pained determination Frau Braun raised herself out of her wheelchair. A physical therapist was at one elbow, an aide at the other; and Frau Braun, between them, labored over the scant four feet between the chair and bed. She had just had her fourth heart attack, a mild one thankfully, but these things add up. Each heart attack was killing off a sliver of vital muscle in the wall of her heart, replacing it with non-contracting scar. As time passed there would be more and more scar, less and less muscle, and then death.
She seemed to be taking it well. It was not what she wanted, but she accepted her fate with dignity. "Not much longer for me now," she said in her thick German accent. She struggled onto the bed.
"No," the physical therapist said brightly, "you are almost finished your exercises." She looked at me, and her eyes said, Who is this dummy? I saw she was satisfied that I knew what she had meant.
It was the beginning of the end — at least her end. She was getting admitted to the hospital every two weeks now, so often that I almost expected to see her when I was covering on weekends. She lived in a nursing home in Arabi, very near the town I practiced in, and the night nurses at the home had a hair trigger when it came to chest pain. She would complain just once of the chest tightness, a page would go out to the on-call doctor (one out of three nights, that was me), and moments later she was out the door in a stretcher.
"Why can't they just give me a pain pill and let me go to sleep?" she would complain. (I think she meant sleep in the concrete, rather than the metaphorical, eternal sense, but who knew?) She always regretted telling the nurses in the home about the chest pain. But after awhile, she couldn't bear the pressure on her chest any longer, nor the "sense of impending doom" medical textbooks predict patients with angina will experience, and she would tell them. And then it was the emergency room.
I had seen her many times in that home. Though I did not regularly go to nursing homes, I sometimes rounded at hers as a favor to my then-partner, Dr. Gold. I had mixed feelings about her. She was crisply courteous and accepting of her lot in life, but she liked to talk and was full of petty complaints. Extraordinarily, she could minimize life-threatening chest pain and yet prattle on for an hour about the food, or about how the nurses at the home were not bringing her sleeping pill to her at 8 pm on the dot. She would fuss endlessly about her fluctuating blood sugars. Not that this was a bad thing, but it was incongruous for a person who otherwise had come to such a determined acceptance of approaching death. Blood sugar obsession might have paid off for her ten years ago, but not now.
After the therapists had guided her into the bed, she looked at me through very thick wire-rimmed glasses. "I talked to the cardiologist this morning," she said. Or maybe she said heart doctor, I don't know. Most educated patients say cardiologist; the uneducated say heart doctor. Or in her case, Doktor. "He told me he would like to do a balloon in my heart to open up a blocked artery. But he already did the balloon two months ago. Why would it work now when it didn't work then? I just had another heart attack. Why would it work now when it didn't work then?"
"I don't know," I said. "He is just trying to do what he can for you. But you are right. It might not work. Angioplasty does not always work." Actually, I was lying. There is no proof than angioplasty ever prevents heart attacks. It can abort a heart attack in progress if the artery is unblocked at very moment the heart muscle is dying. In non-emergent situations, angioplasty reduces chest pain and decreases hospital admissions. But there is not any proof that it affects mortality. Which is the reason I rarely press a patient to get an elective angioplasty when she expresses grave doubts.
"I told him I didn't want it. I don't think it will help. So I asked him if he thought I was going to die. He said, 'That's up to the Man Upstairs.'"
"Well, I would have to agree that . . . "
"I told him, 'There is no Man Upstairs.' There is no one who can help me now."
I can't say her remark surprised me. I had been seeing Frau Braun on and off for the last year, and she had left me with the strong impression that she had no religious beliefs. Some of the hints were superficial, and, I freely admit, merely a matter of prejudicial interpretation. She was German, and there was no escaping the association of Germany with assaults on faith. Hegel, Feuerbach, Nietzsche, Marx, Engels, Heidegger, Frau Braun. And she had ridiculous, out-of-fashion black wire-rimmed glasses that looked like something a bolshevik would wear in a bad movie about the 1930s; their thickness obscured her eyes and thus gave her an expressionless look that a pair of sunglasses would. The glasses also made her look like an out-of-touch intellectual.
Was she an intellectual? I couldn't tell. She was bilingual, obviously enough, and she spoke English, her second language, with a precision that many of my monolingual patients could not. However, when I visited her in her room at the nursing home I could not help but notice how barren her space was. She lived in the northwest corner of a room with six beds in it. She had a portable TV at her bedside, and almost nothing else. No Bible, the ever-present inhabitant of night stands elsewhere at the home — a sign of her unbelief, perhaps — but also, no newspapers, no history books, no novels, no music collection, no artwork, nothing, nothing at all. Taped to the wall was an out-of-focus photo she indicated was her son, but the image was sufficiently blurred that it could have been anyone with brown hair. No traces of an intellectual, a spiritual, or even a personal life.
I had always associated religious unbelief with intellectualism. It takes some doing to reject God — divinity seems a simpler and more natural explanation for the universe — and to decide there is not one usually requires a scientific evaluation of the facts and a rational decision making process that ends in the exclusion of the Man Upstairs. In a certain sense, it takes commitment to desert from the Army of God.
How can someone who has the air of an intellectual have no physical signs of it? Though she looked and acted like someone I should happen upon with her nose in Goethe, I never saw her reading anything, never saw a book or a sign of interest in something besides her TV, what time she got her medications, her blood sugars, and the quality of her food. It is as if the trappings of an intellectual life had abandoned her like her God. If I were to size her up I would say she was a woman who was well brought up, thoroughly educated, who decided shortly after she finished her education that she had learned enough. College-level education, and not a minute more.
It may have been the wearying experience of living in retirement home. In the United States, I know of no more destitute a life. No privacy, sharing a shower with 5 strangers, three miserable meals a day, and a nursing staff that might help you out of your own feces if they are not too busy with paperwork. People in nursing homes have nothing. They cannot — anything worth more than a dollar is going to get stolen. In that same nursing home Frau Braun lived in there was a patient who kept all of her valuables in a grocery sack under a pillow on her wheelchair because she was afraid to leave them unattended in her room. In a nursing home, if you have nothing you can lose nothing.
One of Frau Braun's favorite concerns was her bladder and bowel control. On three or four different occasions she told me she would rather be dead than incontinent, because incontinence left her at the mercy of the nursing staff.
I had asked her on several occasions about her son. He was born German as she was, had married an American woman and lived somewhere in New Orleans. She did not remember where he lived; she had not been to his home in years. They had a son, her grandson, but she had never seen him. Her son apparently visited her in the home from time to time, but not too often I guess because I never saw him in the home or during any of her hospital stays.
After that last heart attack, she waited in the hospital a few more days. Waited for the chest pain to stop, or to die, whichever came first. Finally the chest pain gave in to what vigor she had left and faded away. The next day she went back to the home.
She died a few weeks after that. From my point of view it happened the same way it did with most of my patients — she dropped out of sight. Rarely in the course of my medical practice am I notified of a patient's death. Families think to call every imaginable relative, but rarely the doctor. Perhaps they think that knowing the fine details of the patient in life, I would naturally sense the death. Sometimes I will read an obituary in the paper; sometimes a death certificate will cross my desk, begging my signature. But often the patient will just disappear, leaving nothing but a chart behind. The person's name disappears from my appointment schedule, calls for prescription refills cease, and the medical records move to the archives. Unless I know the patient well, and am accustomed to the rhythm of regular visits, I may not notice at all.
I rounded at Frau Braun's nursing home two months later, and that is how I found out. I was working my way down Hall A, seeing patient after patient, when I arrived at her room. There was no forgetting her room, the door before which I had taken a deep breath so many times in preparation for what I knew would be a thirty minute lecture on the deficiencies in the nursing staff. She was never rude about it, but once she had started on her complaining there would be no stopping her until every single offense was expressed. This time, though, was different. Her name had been stripped from the plate on the door. Her bed was empty, and the mattress bare. If not for the missing sheets, I might still not be convinced that she was gone. She had almost nothing to her name that I could remember, except a TV set and clothing, so barrenness would have been expected. Then I remembered the photo of her son, now gone from the wall.
She was dead then. I wondered if she had a funeral, if she had been buried, or if her body went unclaimed to the city morgue. There was nothing left of her, nothing at all, and her bed waited patiently for some Christian woman to take her place (had to be a woman, since 3 other women occupied the room also; almost had to be a Christian, because in this part of Southeast Louisiana that was simply how it went). The next person to come in and die.
I had to give her credit. She was, to my knowledge, faithful to her unfaithfulness to the end. She stared down death, certain that nothingness was on the other side. Perhaps in her last moments she panicked and asked for a priest, or beseeched the Almighty, but I doubt it. She was close enough to death when I saw her in the hospital after her heart attack, and there was no beseeching then.
When a person of no belief dies, what is to be said of them? Unfortunately, the price of dissolving into nothingness is that those left behind are free to say whatever they want. At least when a patient dies under the banner of a faith, the survivors know what prayers to say, and what symbol to stamp on the grave. For the faithless, there is only embarrassed silence.
Or maybe memories. We carry with us the memories of everyone we have ever known, and in a way, the deceased live on in others' memories. So she lives on as a meme in my brain, and now I pass this meme on to my faithful readers.
Some of us would prefer to pray for her. I think Frau Braun would not object — she was not a confrontational woman — but she would probably prefer the meme.