Making Rounds with Oscar: The Extraordinary Gift of an Ordinary Cat - By David Dosa Page 0,17

with the question of whether a diagnostic workup for an everyday problem makes sense. Will I do anything even if the patient has cancer or some other disease? If not, why order the test?

Where Alzheimer’s is concerned the roller-coaster ride of acute illnesses followed by partial recoveries can also leave families with a false sense of hope. I’ve had family members tell me, “If we can just cure the pneumonia, I know Mom will get better.” “If we can just get Dad over this hump, I’m sure we’ll see some progress.” Families become preoccupied with the notion that if the patient is sent to the hospital and cured of his pneumonia (or his staph infection, or his broken hip), he’ll eventually be healed. Lost is the fact that the chronic disease progresses steadily despite the recovery from the acute event, leaving the patient considerably weaker and less prepared to deal with the next challenge.

But finding a place to draw the line in patients with dementia can become challenging and fraught with ethical dilemmas for both the next of kin and the health care provider. It was that way with Frank and Ruth Rubenstein.

“DR. DOSA, I need you to see my wife right now.”

The assertiveness in Frank’s voice sent Oscar, resting peacefully on the countertop, scurrying for cover. He found it under the desk between Mary’s legs. If I had been quicker, I very well might have joined him.

“What can I help you with, Mr. Rubenstein?”

“It’s Ruth. She’s more confused today than she was yesterday. And she’s not eating. I’m worried about her.”

“Let me finish with a few things here at the desk and I’ll be down in a minute.”

My response was met with a glare and for a moment, I thought he might wait at the desk for me to finish whatever it was I had to do, but he turned away eventually, muttering something under his breath. I had to remind myself that he was concerned about his wife and that his concern was manifesting itself as, well, old-man grumpiness.

“So, do you want to tell me what this is all about?” I asked, turning to Mary as he disappeared.

“Ruth’s not doing so well lately, David. She’s not eating and she’s dropped a few pounds. I suppose he’s worried that we’re not taking her weight loss seriously enough.”

“How much weight are we talking about?”

“About ten pounds.”

I frowned. The irony is that so many of my patients could stand to lose ten pounds to help with their diabetes, hypertension, or cholesterol but not Mrs. Rubenstein. The 5'2" lady was probably 110 pounds sopping wet the day she entered the nursing home. Ten pounds was a big deal.

“Do you think anything else is going on?”

Mary shrugged. “I suppose anything is possible, but I honestly think her dementia is just getting worse. By the way, he’s asked for a referral to a gastroenterologist. He’s worried she has colon cancer.”

In a healthy patient, the idea of seeing a gastroenterologist for a colonoscopy to evaluate weight loss would certainly be indicated, but with Ruth’s rapid mental decline, the prospect of subjecting her to multiple tests and procedures was probably not in her best interests.

“Have we started any discussions with Frank about limiting his wife’s care?”

“David, I don’t get hazard pay here.”

I sighed as I looked at Oscar curled up in a ball in a nook under the desk.

“You got any space down there for me?”

“Nice try, David. I talked to him last time. It’s your turn to go talk to the man.”

MY FIRST MEETING with the Rubensteins had ended so badly, I was a little surprised when I saw them return. Frank had been angry and Ruth was scared—a classic tag team of denial. I suspect that they went to other doctors with the hope of finding a different answer. That’s common enough: I’d probably do the same. Perhaps they simply decided not to deal with it at all. But burying your head in the sand only works for so long. After about a year, they returned to my office and became regulars.

For a while, their visits to the clinic were positive. With each subsequent appointment, the couple seemed to accept Ruth’s diagnosis and did their best to deal with it. Then Ruth began to lose many of the social graces that masked her memory impairment. Embarrassed by her worsening power of recall, she withdrew from her friends. As a result, she became depressed. Medications for depression helped briefly, but did not curb the persistent