Mr. Kraatz stood by the door to the examining room, shifting his weight every few minutes restlessly, looking down the hall, waiting for the specialist to enter. Sitting very still in her electric wheelchair, mute, his wife appeared calm and strangely peaceful. I'd been sent in to interview them, to gather all of the information I could think of, before Dr. Black arrived. Being a first-year student, I ran out of questions quickly. So I began to make simple conversation, convincing myself that I was practising my interview skills and developing rapport. But really I was just terrified of the silence in this sterile little examining room.
Friendly questions like “Do you have any children?”, “What work do you do?” and “What's it like outside? I haven't been out all day … .” didn't last long either. A lull ensued. My hands fumbled as I tried to appear occupied with the patient's chart in industrious oblivion to the couple's intimacy. Mr. Kraatz sat down on the hard white thermoplastic seat available to him near the door. He stared across the small room at his wife of 20 years for a time that seemed almost endless to me. They were communicating somehow without words. As I watched their amazing interaction unfold, it was as if I were not even there. But the memory of their thick and sorrowful passion was etched on my soul that day.
“You know what he's going to say, don't you?” he asked his wife out loud. She nodded. “And you've made your decision?” She paused for a few seconds, returning his gaze with an incredible intensity of purpose. Then she slowly nodded assent, and her long honey-brown hair fell across her forehead and cheek, shrouding her now expressionless face. He closed his eyes, his mouth quivering for just an instant. Then he swallowed and stared back into her unwavering eyes. “You know I'm behind you all the way, whatever you want. I'll be there ... you're my girl always.” His voice trailed off, trembling, as her face softened and she gazed tenderly at him. The corners of her mouth raised into a small smile while a few tears silently ran down her face. With shaking hands she slowly pressed the keys on her communication device; an indifferent artificial voice verbalized “I love you forever.” He turned to lean his lined face against the stark hospital wall.
Dr. Black made his entrance, and I gave him my 27-second synopsis of Mrs. Kraatz's progress. He dismissed the report quickly and began to take his own history. Mr. Kraatz listened, his face still against the wall, as the short, gray-bearded doctor flew through a barrage of questions while his shiny blue fountain pen scribbled assiduously. Was she getting weaker? Was she having more difficulty dressing herself, swallowing, managing her own drool? Was she starting to have nightmares? Headaches first thing in the morning? Some of the questions made sense to me; others, I would never have known to ask. When he finished gathering the information, he paused to make some more notes. He then turned to Mrs. Kraatz.
“We have now come to a crossroads in your disease. We have talked about what might happen in the future if your respiratory muscles began to get weaker and your sleep became affected. It is now time to make a critical decision. Do you wish to proceed with artificial ventilation during the night? If you decide against it, we must be clear that you understand the potential consequences. You are starting to have consistent nightmares and headaches in the morning and your sleep study shows that you are having short periods during the night where you stop breathing altogether. These are called apneic episodes. If you don't start using artificial ventilation at night there is a risk that one night you will stop breathing and never wake up. Have you thought about what you want to do?” Mrs. Kraatz's eyes moved toward her husband, momentarily appearing anxious and frightened. He turned his head and looked at her. His eyes were brimming with tears, but he remained silent as he looked deep into her eyes. He forced himself to smile and nodded his support. She breathed out slowly, and started to key in her thoughts on the computer.
“I want to fall asleep. No machines.” The artificial voice, eerie in its indifference, echoed in my head and chest. I felt sick to my stomach as Dr. Black reconfirmed her decision, made additional messy notes in her chart, shook hands with Mrs. Kraatz and her husband and indicated to me that the interview was over. We were to proceed to the next case. As we left the room, I awkwardly mumbled my good-byes to the couple. Mr. Kraatz moved to his wife's side to embrace her. The door to their lives was now closed to me. Dr. Black stopped me outside the examination room.
“How are you feeling? You look a little pale.”
“I'm ... I'm fine, I suppose. I just feel really …”
“Helpless? Overwhelmed? Cold? I did too, at your stage. I still do sometimes, but I deal with ALS patients all the time so I can't afford to let it get to me. There's only one patient left to see. Why don't you go home early? I think you've probably learned something about life and death today. Go home and think about your experience here. Think about how lucky you are to have your health. Think about the things you enjoy doing in life, your friends and your family. And also, think about why you really want to be a doctor. Sometimes we do help people get better when they are ill, but our responsibility also lies in helping people die with dignity, comfort and, perhaps, a little sense of control.” He smiled at me sadly, then moved on to the next room.
And so I walked home, feeling numb. And feeling privileged to see what I had seen that day.