Viewpoint

Nothing Left to Lose

FROM THE CHIEF MEDICAL EDITOR

Larry E. Patterson, MD

Last fall, I saw a 62-year-old retired psychotherapist/drug counselor who complained of blurred vision. She was kind enough to bring her two-page typed chronological medical history in bullet point format. You know the type — detail oriented, organized, type-A and completely together. I always take a deep breath before I go in to see patients like this because I know it's going to be 20 questions… or so I thought.

I entered the room to find a disheveled woman smelling of brandy who at 10am was already three sheets to the wind. Upon examination I discovered that in addition to her inebriation, she had significant cataracts and needed surgery. I explained that she could not eat or drink anything the morning of surgery, including alcohol. She scoffed at the notion and quick-wittedly clarified, “I've spent too many years of my life doing what I was supposed to do and now I have cancer and am going to die, so I'm gonna have brandy in my coffee every morning if I want it!” We repeatedly stressed the importance of being NPO the morning of surgery and with fingers crossed we scheduled her as our first case.

She called the day before surgery to ask how long she would be at the surgery center because she was coming in a taxi. When asked if she had any friends or family that could help she replied, “Nope, I live alone with nine cats.” When asked if she had begun the preoperative eye drops she replied, “Some of them.” After a lengthy discussion and the patient's detailed explanation of her inability to open the bottles, even with pliers and a screwdriver (the tool, not the drink), we surmised that she likely had them open now, but had not used them. When she was cautioned that she could go blind if she didn't use the drops correctly, she assured us that she would definitely use her drops.

At 7am the day of surgery, our patient arrived lit up like a firefly and smelling of brandy. As best, we could tell she had used at least some of her drops. After a lengthy discussion with the patient and with our surgical staff we decided to proceed with surgery without additional sedation. It was obvious that this situation was never going to get better and rescheduling her appointment wouldn't do any good. She lived alone with 20/100 vision and if we could just get one eye done, it would significantly enhance her life.

She saw 20/20 uncorrected the first postop day. As expected, she did not use her drops correctly after the surgery and subsequently developed iritis. I think my surgical coordinator enjoyed being very direct, giving her the most painful, worst-case scenarios that might result from not using the drops, in an effort to get her attention. You could say anything to her and she'd come back with a hysterical comment and would always say, “Ah, I'll die before I lose my vision!” My staff and I didn't know whether to get aggravated or laugh. We eventually chose to laugh with her. Three days after her two week postop visit, I sadly received the notification that she had died. In the end, she was right.

Even our best surgical outcomes couldn't motivate her to change her behavior and comply with instructions. She just didn't care. Her attitude recalled the song lyric, “freedom's just another word for nothing left to lose.” I hope this lady took some solace in the freedom of her final days. For us, it was worth the effort to know we were able to make a difference in her life, at least for a while.