It was harvest – a time that I have grown to respect after moving to the fertile plains of Kansas three years ago for residency. During this time, a family would learn whether the year of hard labor had reaped financial stability. Harvest had a heightened importance in the Sahel. Located on the edge of the unforgiving Sahara, it has some of the worst poverty on Earth. One month of rains were the only chance for income and food for most of the Hausa people I was there serving. Harvest and its hard work brought hope that perhaps fewer children would starve this year.
It was poor timing for a "70” year old man to become so short of breath that walking was no longer possible. Convention was to guesstimate ages to the nearest decade, so his true age was unknown. He had breathing problems and swelling in his legs for "a while,” but he had lacked the finances, time, and hope needed to seek out medical care.
This time, however, it could not be ignored. His two sons gathered the money from a few relatives, borrowed a small motorcycle from yet another, and sandwiched their father’s weak body between theirs. They left their millet fields and children, and journeyed towards the hospital. Both sons were needed, as most of their father’s care at the hospital, even food and water, would depend on them.
His diagnosis of severe heart failure was readily apparent, and his low oxygen and labored breathing made me worry that he would not survive. But this man was not yet on any medications. I convinced myself that this might be one of the dying patients I could save. I started the most aggressive therapy we had available and waited.
By the next morning he was even worse than when he arrived. He was now unable to lie down in his hospital cot lest fluid accumulate in his lungs and suffocate him. His sons began taking shifts – sitting behind their father with a leg straddled on either side of his, arms gripped backwards around the cot’s frame to support the weight of their father’s frail body on their chest.
Back home I worked part-time at a hospice. I was accustomed to coaching families through the last days. I was used to families enduring all the appointments, the tests, the ICU’s, the battles with insurance companies, the mixed messages, and the roller coaster of expectations, all fueled by a burning hope that "we can get dad better”. Eventually, that hope yielded to an acceptance that this just might be "his time to go.” Through compassionate communication, I would elicit the family’s true goals of care (comfort, dignity, meaning) and help arrange for those to be met as the end approached.
Among the Hausa, however, death is well accepted, even in children. Yet these young men endured anyways. Why? For days these two sons propped themselves upright on the colorful woven cot, patiently bearing their father’s weight in order to help him to breathe. As I saw them each morning, unmoved, I myself was moved to tears. I owed them my best. Though recovery seemed less likely each day, I would ask their permission to try something else, to give it one more day. Maybe we could turn this around. As I informed them of my thoughts and presented them with options, their response was always the same – nothing. "Just tell them what to do,” my translator would tell me. There was never a hint of frustration, tiredness, or impatience.
I came to accept that their endurance was not fueled by hope for a miraculous recovery. I think, rather, that they were fueled by unquestionable respect for their father, the man who taught them how to live and work, what it means to be Hausa. In fact, they recognized and accepted the end a few days before I did. When I recommended that they disconnect his oxygen and carry their father homeward, they simply accepted with a stoic nod of understanding.
We talk a lot about heroic measures in our healthcare system. By this we imply resources: medicines, monitors, tubes, consultations, procedures, devices, etc.
However, the most heroic care, the care that I will desire when my time comes, has little to do with payer source or access to resources:
Respect. Compassion. Physical presence. Physical touch. Tenderness. Sacrifice. Patience.
I think these sons, and their father, reaped a more meaningful harvest than grain this season.
||Patrick L Allen, MD, studied at Texas A&M University, then the University of Texas Medical School at Houston before completing his Family Medicine residency at Via Christi Hospitals through the University of Kansas - Wichita. His interest in Global Health and Tropical Medicine led him to pursue a one year International Family Medicine Fellowship, which included 5 months of intensive service in Niger. He is also passionate about primary care medical education, both domestically and abroad.