Dr. Glynn's decision was life or death.
A thin old man stepped into my office with faded yellow slacks, a threadbare blue sweater and saddle shoes that seemed too large. He held up a plastic inhaler and through pursed lips gasped, "I think I have emphysema."
Ray (not his real name) was 70 and had recently quit smoking. As I examined his spare frame and took his history, I couldn't help but privately chuckle at the curly gray hairpiece he hadn't removed.
Ray told me he'd grown up as a caddie in Oklahoma and turned pro when he was 20. "Played on the tour some back in the '30s and '40s. Competed against Hogan, Snead, Nelson. Paul Runyan and I were friends."
I mentioned I had Runyan's book on the short game, and Ray's voice perked up. "You play golf?"
"I like it, but I'm not very good."
Widowed with no children, Ray taught at a public driving range not far from my office in San Diego. I prescribed him medication and breathing exercises and started seeing him every two months. Each time he came in, he'd ask how my game was. My answer rarely varied: "Not playing much."
Ray's reply also rarely varied: "Come down and let me have a look at you."
After a year of these invitations, I relented. Ray conducted my lesson from a canvas director's chair, and his only teaching aid was an old photograph of himself at impact. "Make it happen from behind," Ray said, his way of emphasizing that the hips must lead the downswing.
Ray continued to see me, and I him. Though my swing was showing glimmers of hope, his health was not. Too weak to drive, Ray started canceling my lessons, and then his appointments.
So I made house calls. Ray lived in a tiny studio a mile from the ocean. It had a Pullman kitchen, a musty bed and a single closet. His neighbors were surfers. Depressed by his isolation and knowing the natural course of his illness, I worried. There was no next of kin with whom to discuss the hard questions, and Ray was reluctant to talk about the end.
I had the idea to invite Ray for a "playing lesson." We took a cart, and near the greens he would remove his oxygen tube to chip and putt. Despite his difficulty breathing, he seemed to enjoy himself.
"That was pure," Ray said after we finished.
"Let's do it again one of these days," I said. Though I knew the odds.
The call came on a Monday afternoon. My assistant interrupted me while I was with a patient to tell me Ray was on the line, and he sounded real bad. I ordered an ambulance.
When I met Ray in intensive care, I found the staff had inserted a tube into his trachea and had begun mechanical ventilation. Without his hairpiece, Ray looked shrunken and desiccated. He was in agony, and his eyes were filled with pure terror.
I slept poorly that night. Statistically, if we kept Ray on a ventilator and administered steroids, he had a 75-percent chance of stabilizing and maybe living another year or two. But Ray wasn't a statistic. Because of golf, Ray was my friend. Wouldn't it be cruel to commit a friend to perhaps weeks of discomfort on a breathing machine, all so that he might spend more days languishing in that apartment or a nursing home? Then again, who was I to decide what constituted a life worth living?
The next day, because Ray's blood-oxygen and carbon-dioxide levels were satisfactory, I could justify the decision to disconnect the ventilator. I held Ray's hand as the nurse removed the tube from his throat. He was unresponsive. "Remember, no CPR if he stops breathing," I told the nurse as I left the room. Ray died that afternoon. He was 72.
This was 1981. I was 45 then, and it so happened Ray's case coincided with my maturity as a physician. Less preoccupied with following procedure, I was gaining the confidence to ask bigger questions. Perhaps it would've happened later, but Ray's case ignited my campaign to establish a bioethics committee at Scripps Mercy Hospital. I wanted colleagues to consider if using the full application of technology was always the right decision.
Now I'm 76. Mostly retired, I'm finally making better use of my membership at La Jolla Country Club
. Though death is part of a physician's career, I can look back on my work with peace because of the deeper thinking I helped initiate in the medical community around me.
It's often that I still think of Ray, and making the swing happen from behind.