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Sitting ShivaOur longtime veterinarian looks like a CEO of some big corporation, yet his demeanor is what you’d expect from a man working with pets--calm, precise, and affable, even when discussing something potentially emotional, like euthanasia. He is Bill Gates in a white lab coat with sleeves too short for his arms, Mister Rogers with a mustache. “She must’ve been the runt of the litter,” he said the day we brought her in for her first exam. “But that’s OK--runts make great family pets, they have personality.” But what I remember about that visit is how he picked Yentl up--the way he cuddled her close to his cheek somehow reminded me of the way new mothers handle their newborns--and I immediately liked him. I liked the gentleness of his touch, his soft voice, and, of course, his doctor-like honesty. “She’s kind of scrawny for an Airedale,” he said after finishing that first exam. “Her tail was cut a little bit long and her ears will need to be pinned down or they’ll stick straight up for the rest of her life. I hope they gave you some break on her cost.” Two hundred dollars--the same price of her littermates. But despite her small size and her oversized nose we chose her anyway. Actually it was my wife who did the choosing. “We’ll take that one,” Jennifer said after watching this incredibly ragged-looking pup try again and again to climb her way out of the metal pen she was housed in. “She may be small, but damned if she doesn’t have some character. I like dogs with character. Character is as important in animals as it is in people.” Yentl’s ears still stick straight up like radio antennas. Still holding the syringe in his hand, Dr. Nightingale walks out from behind the exam table, kneels down in front of me, and tenderly strokes the knots of brown fur that have matted on her back side. Yentl doesn’t seem to mind, in fact she remains motionless, even when he pinches a cleft of skin between her shoulders and injects the clear blue fluid under the skin of her neck. “Nice puppy dog,” he whispers into her left ear. “You’re a pediatrician, you understand.” He stokes her fur and talks to me at the same time. “Treating animals isn’t much different from treating kids. They’re innocents--most of the time they don’t know what the hell we’re doing to them. That’s why I chose veterinary medicine. No patient biases or pretenses.” When he’s finished his final caress, he stands up, wipes his hands off on his lab coat, and then spends a couple of minutes methodically rearranging the equipment on the table. He looks a little preoccupied--perhaps he has another sick animal somewhere else in the building, or maybe he is simply thinking about lunch--but before he walks out of the room, he stops at the door and points at the clock on the wall. “I’ll be back in fifteen minutes,” he says. “Wash your hands. Since you take care of babies in the hospital, you must be pretty good at placing IVs into tiny veins. Wash your hands. I might have to call on you for some professional help.” *** On Tuesday nights, I teach medical ethics to Jewish high school students. My talk on euthanasia, one of their favorite topics, begins with a Talmudic perspective. The Talmud says that Death, besides being inevitable and just, is handed out only by God. Our bodies, the physical self we are housed in, is temporary, while the soul, or nefesh as its called in the Torah, can only be relinquished through His mercy. Because of these tenets, most Jewish scholars conclude that suicide or any act of euthanasia, irrespective of terminal illness and the pain and suffering that may go along with it, is strictly forbidden. The teenagers in my class disagree. They believe they are the real proprietors of their bodies and souls, and that they have the right to make all decisions regarding its care and demise. Their arguments include specific case examples: the abortion of an unwanted pregnancy, pulling the plug on a loved one who is brain-dead, and assisted suicide under the guise of terminal illness. “If your body was full of cancer and you were suffering needlessly, shouldn’t you be allowed to die with dignity?” one of them asked me in class one night. For a moment I didn’t respond. I was thinking, instead, of my rabbi, my Bar Mitzvah tutor who used to counsel me on different ways the Torah could be interpreted. Rabbi Moskowitz wasn’t a typical rabbi; he was large and imposing, clean-shaven and young looking. He also often questioned some of Judaism’s more traditional teachings. It’s the spirit of the law that’s important, he used to say. The Talmud has evolved throughout the years by a constant debate and ongoing discussion. We must continue that process to continually update our laws and ethics to keep up with a society that is becoming more enlightened. Several years later, at the young age of forty-six, Rabbi Moskowitz killed himself. Keeping his diagnosis of Multiple Sclerosis from his congregation and not wanting to burden his wife and eight-year old son with the needs of a hopeless invalid, he closed himself in his garage and let his car fill with carbon monoxide gas. And on that Tuesday evening, when asked if I would rather die than live with intractable pain, I simply nodded my head in the affirmative. What choice did I have? As a Jewish educator, what do you say when the Torah and the pit in your stomach are in complete opposition? *** Yentl has survived a turkey bone in her trachea, a rubber ball in her pyloric outlet, and what we thought was a severe bloody wound in her mouth, but was really a bottle of Hoisin sauce that she had pulled out of the garbage and thoroughly licked clean. She survived all of her littermates as well as the wrath of my wife Jennifer, who for the last two years has woken every morning at three o’clock to let her outside so she can sniff around the yard for an hour before she finally settles down to pee. “I thought this bullshit of getting up in the middle of the night was over,” she said to me one morning after a particularly bad stretch of nights in which Yentl would disappear in the yard and then scratch on the door just as she was about to fall back asleep. “Our children have been good sleepers since they were two months old. What’s up with that? Why am I the only one in this house who isn’t getting any rest?” She didn’t actually say the words, but what Jennifer was alluding to was my un-doctor-like ability to shut out the world between midnight and dawn, a trait not conducive to being a good pediatrician sympathetic to all sorts of after-hours phone calls. She was also holding tight to her emotions; in reality she was very fond of Yentl. For instance, every time I mentioned the idea of putting her to sleep, Jennifer’s eyes would water and tear, just like when she happens to catch the end of “Homeward Bound,” a movie our children used to watch. In the movie its mammalian stars--two dogs and a cat--scrap their way back across harsh country to reunite with the children who once cared for them. None of the damn animals actually die, but every time Jennifer sees the old hound dog limp out of the forest and trot into the arms of his grief-stricken little boy, her eyes begin to fill. “You can’t put a dog to sleep just because she can’t control her bladder,” she says whenever I bring up the subject. “How would you like to be euthanized just because you have to wake up in the middle of the night to take a piss?” Her tone finally changed the day we found Yentl lying on our Mexican Tile floor, her snout in a small pool of blood. And when Dr. Nightingale diagnosed the mass in her upper palate as a squamous cell carcinoma and told us she had about two months to live, we sat in the exam room discussing, not the best treatment option available, but the most convenient time to have her euthanized. The most convenient time had several variables. “We decided to wait a few days,” we said when Dr. Nightingale returned to the room. “We want to be able to tell our children first.” The past summer our youngest cat Cooper had suddenly became ill and we made the mistake of having her put down the same day that we brought her in for the evaluation of her illness. Emily and Jonah were quite distraught when they found out that they hadn’t been consulted or allowed to say a final goodbye, and we vowed to do it differently the next time around. On the way home from the vet, Jennifer set the record straight. “You’re the one who is bringing Yentl back for the final appointment,” she said. “She’s really your dog, and besides, you’re the doctor--you’re used to this kind of stuff. What is it you always say to me? ‘Animals don’t have the capacity or intellect to understand grief. With all the tragedy in the world, you ought to save your tears for those things, the people things.’” Then she paused, keeping her eyes focused firmly on the road and her hands gripping the steering wheel. “You are the doctor,” she said, her voice returning to normal. “You can bring her back to Dr. Nightingale and sit in that room and watch her die. Watching a dog being put to sleep isn’t a part of my job description.” *** People assume that physicians are immune to sorrow and grief, my family included. Halfway through my first year of medical school, my grandmother asked me to stay at the hospital the night my leukemic grandfather’s condition took a downward turn. What she didn’t understand, and what many fail to realize, is that first year medical students rarely see the inside of a hospital, much less a person who is sick or dying. We attend lectures in the morning, labs in the afternoon, and spend our evenings and nights pouring over pages of scribbled notes and esoteric text. But that night I stayed, and an hour after Mt. Sinai Hospital emptied its visitors, I saw the physiological changes occur in my grandfather that I had just finished reading about in my pathology book. “Kussmaul’s breathing,” I said to myself when his respirations quickened. I recounted the text. Dying organs eventually stop metabolizing acid, and as the acid builds up in the tissue, the lungs respond to the acidosis by working harder--breathing faster, thereby blowing off carbon dioxide in an attempt to keep the acid-base system in homeostasis. That night I sat at my grandfather’s bedside, holding his hand, and glancing between the second hand of the wall clock sweeping across its heavy black numerals, and his face, which had sunken deep into his pillow. I counted the number of his breaths by watching the mist of steam climb up and down the inside of the tubing hooked into the end of his nose. Then his breathing changed--it became more labored and erratic--and I watched him take a series of rapid, shallow breaths interspersed with a few short intervals of apnea. Cheyne-Stokes Respirations: a dying man’s final efforts to breathe, a sign that the acidosis was becoming irreversible. Finally his chest heaved once, his lips pursed, and after a few horse-like snorts, he sighed deeply and stopped breathing. Just like that. No strange sounding alarms, no high-pitched beeps, no flat line monitor hum, no last dying words. He simply sighed and stopped breathing. “An agonal breath,” I thought to myself, and after calling for the nurse, slumped back in my chair, waiting for the final arrangements to be carried out. While I waited I stared at the phone sitting on the table next to the bed. On 49th street, between Capitol and Locust, my grandmother was probably looking at her phone too, alone in her living room, her last instructions to me to call her the moment something happened. Being the first grandchild, she had said, made me the one that Grandpa Harry wanted in the room that night. The first grandchild, the favorite son, the boy who grew up to be the family’s first doctor. I reached over and picked
up the phone. I held the receiver in my hand for an eternity before I called
my grandmother and told her the news. And in a very un-doctor-like moment,
I told her that Grandpa Harry’s last words were, of course about her.
*** Dr. Nightingale’s exam room looks surprisingly similar to the rooms at my office: a long rectangular table in the center, molded chairs in the corners, and pictures of happy children playing with rambunctious dogs in rushing streams and wooded forests. Shiny waxed tiled floors and the strong smell of iodine covering a trace hint of urine. Two days ago I explained Yentl’s dire situation to my seven-year-old on the way home from school. “Yentl is pretty old for a dog,” I said, glancing into the rearview mirror. “She’s lived a long and happy life, but now all she does is sleep. And have you noticed how she always limps. It’s even hard for her to walk from one end of the house to the other.” Jonah stared back at me in the mirror. At first his eyes took on a heartbreaking sadness and I thought he might start crying. But the look didn’t last long. The minute I stopped my explanation, his expression changed. His face brightened, his eyebrows pointed up, and his eyes lit like I had just suggested a trip to Dairy Queen or Baskin-Robbins. “Do you think we can we get
another dog today?” he asked.
Yesterday, my ten-year-old Emily came home from summer camp. At age three Emily didn’t talk for a week when her grandfather was killed in an automobile accident, and at eight was so disturbed by the dog’s death in “Sounder,” a story of a black family surviving in the South, that she refused to read anything other than Calvin and Hobbes comic books for the next three months. I broke the news to her on the way home from the airport. “Yentl has cancer,” I said, bluntly. “Dr. Nightingale wanted to put her down on Monday, but we thought we should wait until you came home and had a chance to say goodbye to her.” Emily didn’t respond, but as soon as I garaged the car, she headed straight to the bedroom where Yentl had been spending most of her down time. She closed the door without a sound, and five minutes later she walked out, her face looking remarkably similar to the day she found out about her grandfather’s death. “I’m not going back in there, Dad,” she said, barely speaking above a whisper. “I’ve said my goodbyes. And please don’t ask me to talk about it, either.” And true to her word, she didn’t go back into the bedroom, nor did she ever talk about Yentl or the return visit to the vet that I had arranged. And I honored her wishes by not bringing up the subject again. In my daughter’s mind, Yentl was already dead. *** When suffering the loss of a loved one, Judaism encourages us to face reality. The bereaved are expected to shovel the first dirt onto the casket, to rip a tear in their garments, and to sit shiva for seven days in the home immediately following the funeral. Shiva, the Hebrew word for seven, is the required mourning period for Jews, a time of solemn reflection, a time when visitors come to the home of the grief-stricken in order to help them cope. Proper etiquette at a “shiva call” dictates that the home is entered silently and that no one speaks until spoken to. This tradition, borne out of Talmudic law, allows the grieving person to talk only when they feel like it, rather than in response to an awkward silence or inappropriate comment. It allows the uninitiated expression of emotion. So aren’t physicians always on shiva call? We listen to people’s troubles, we answer difficult questions, and we are the ones chosen to relay the news of a dismal diagnosis or God forbid--Death. And during these interactions we must be purely professional; tell only the straightforward facts, give no false hopes, and don’t expose or reveal personal feelings. We must, in effect, mediate death without letting it touch any part of our inner soul. That is what the textbooks tell us we should do. From the moment we open the metal tanks with cadavers that we will dissect and dismember, to the moment we watch that first vulnerable human succumb to the diseases that we have studied, we’re constantly surrounded by disease and its mortal consequences. Yet we’re not taught how to respond as a human being. I have held a cirrhotic liver in my bare hands and have done compressions on a chest whose heart quit beating fifteen minutes earlier. I have administered intravenous nutrition to a baby born without a brain and have driven a three-week old infant to the morgue because his withered left ventricle precluded his survival. And I have sat in a chair and watched my grandfather, the cherub-faced man who I once promised that I would become a physician so I could buy him a tall building, take his last breath. So by comparison, taking the family pet to the vet for an injection that will painlessly stop her heart is nothing. It’s a simple task, really. Animals, after all, aren’t quite human. They don’t talk, laugh, cry, or reason. They don’t think like we do; some will run aimlessly out in the street with a car bearing down on them and some will wag their tail in the face of an abusive owner. There are even those simple-minded animals who don’t have the common sense to come in from the backyard in the middle of the night when it’s cold and raining and both of its owners are trying to sleep. *** Yentl’s tongue lolls from her mouth, a pool of saliva forming on the tile underneath her. The Thanksgiving that she tore open a green plastic trash bag of garbage and ate it contents while we were outside saying goodbye to our guests was the same day she escaped into the desert during the pre-dinner cleaning spree. I missed more than half of the Lions-Bears football game searching the neighborhood, only to finally find her asleep in the corner of the garage, a piece of cactus dangling from the end of her nose. When Dr. Nightingale walks
back into the room, he’s holding a different syringe and this time has
a red flannel blanket draped across his arm. He spreads the blanket out
on the exam table, motioning for me to pick up Yentl and lay her across
it. “She’s really out of it,” he says, staring at the slimy tongue hanging
from her mouth. “The sedative has done its job. She won’t feel the IV and
she won’t experience any sensations when I give her the final injection.”
I stand back and watch him wrap the rubber tourniquet around her front leg, wipe it off with alcohol, and then stick the needle into a hidden vein. After drawing back on the syringe to ensure the needle’s placement, he slowly injects its contents. Yentl doesn’t move a muscle the entire time, and for the next minute or two, both of us, pediatrician and veterinarian, stand over the table watching her breathing slow. While he leans over her chest and listens for a heartbeat, I consider the things he has said in the past. How pediatrics, like veterinary medicine, is a relatively happy field. In a private practice setting children rarely have life-threatening illness and almost never die. In ten years I lost only one patient--a newborn with a congenital heart defect. What Dr. Nightingale also meant is that our fields are relatively free from heartache. Children don’t die, and when animals do, it’s not such a bad thing because they don’t know any better. Children are healthy creatures, and animals are…well animals are just animals. Dr. Nightingale strokes Yentl’s back one more time. Then he wraps her limp body in the blanket and walks over to the sink where he washes his hands. “We have an arrangement with the funeral home down the road,” he says, drying them off on his coat. “Our cremations are cheap--they’re done wholesale. Many of our clients opt to keep their pet’s ashes at home. Would you like a ceramic urn put on your office charge account?” *** There’s a moment, maybe a second or two, where something inside of me attempts to wrestle free. I’m standing at the back entrance of Dr Nightingale’s office, about to walk out the glass door that’s inscribed with his name, when something grabs a hold of me and makes me stop in my tracks. Maybe it’s the leash dangling from my right hand or maybe it’s the bowl of dog treats sitting on the counter staring me in the face, but for an instant I feel as if my knees are about to buckle and I might simply crash to the floor. But when I push through the door and a blast of furnace air explodes in my face, the feeling passes and the strength slowly returns to my legs. I open all the windows in my car and begin the drive home, thinking all the time about the effects that Yentl’s absence will have on my family. I know that Emily will do her best to hide her emotions and that Jonah will be upset for a couple of days, but will get over it the moment we begin discussions on the next family pet. And eventually we will get another dog--probably not an Airedale and definitely not a runt--and before long Yentl will remain as memories in our minds and the home videos sitting on our shelves. Some will be happy memories, like the time Yentl stretched out across the couch to protect Emily’s cradle from the prowling cat, or the time she ate Hoisin sauce and we thought she was slowly bleeding to death. And of course there will be images that will cause our eyes to roll, the stories about her pain in the ass antics the last few years of her existence. Though the billows of hot air that blow in through the car windows are keeping my eyes dry, I’m left with a deep hollowness in my stomach that I can’t quite articulate. It’s a strange feeling; not the same washed out numbness I experienced the night they rolled my grandfather out of his hospital room, and not the creeping heaviness that slowly seeped through my chest the day my mother called to tell me that Rabbi Moskowitz had committed suicide. But there is no denying the feeling is there. There is an emptiness that I know won’t go away any time soon, even after the purchase of a cute and willful puppy that will win my children’s hearts the moment we bring her home. And as I get closer to my home, I think about what Jennifer will say to me when I come into the house holding Yentl’s empty crate. Will she break down and cry? Or will she wait for the comfort of the night when the children are safely tucked in and sleeping? And how long will she mourn--how soon will she be ready to replace our beloved pet with something that is the same but different. And as I drive home one last question enters my mind: Will Jennifer really be happy now that she’ll finally get to sleep through the night, totally uninterrupted? |
