The Face of God Revealed

• patient-practitioner relationship
• end of life care
• caregiver

Many years have passed since I visited Donny and his wife Rose (not their real names) in the hospital. Donny was admitted with a pleural effusion that was due to a newly diagnosed and aggressive lung cancer. It was a readmission for the same problem, since he had summarily checked himself out a week earlier after hearing that he had a malignancy. As his family doctor, I knew that Donny dealt with any thoughts of cancer with a volatile mix of denial and rage. This was a challenge during appointments when he would complain of a persistent cough. I once voiced my concerns about his symptoms, his longstanding history of smoking and alcohol use, and the possibility of cancer. Donny unloaded on me with a fusillade of expletives and I did not use the word “cancer” during a clinic visit with him again.

After Donny’s untimely discharge from the hospital, Rose called me expressing anger at her husband for his pig-headedness, and with fear about his declining condition since he could no longer complete a sentence without stopping to catch his breath. I asked Rose to put him on the phone and could hear Donny wheezing and coughing as he made his way to pick up the receiver.

“Dr Daaleman, I don’t have cancer and don’t want some jackass telling me that I do!”

The winds of Donny fears were blowing with full force and I was heading into stormy waters.

“Donny, I don’t know if you have cancer,” I started cautiously. This was true since he had refused a lung biopsy. I was aware, however, that the pulmonologists and oncologists who previously cared for him uniformly agreed that he had metastatic lung cancer. Donny didn’t immediately respond so I waded further into the tempest.

“I can hear you struggling with your breathing. And I’m worried this will get worse and you won’t be able to get along, even with Rose’s help,” I continued in an even tone before delivering the pitch, “I think you’d be better off back in the hospital.”

His labored breath sounds filled the silence between us.

“Donny, whatever your condition—it may be cancer, it may not—this is causing fluid to build up in your lungs,” I said. “Whatever the cause, we need to get you back in the hospital to place a tube in your chest to drain the fluid out so you will feel better.”

“Awright, Dr Daaleman,” he finally blurted out, either from resignation or fatigue, “I’ll go, but I don’t have cancer!”

“Donny, with your condition, I think this is a good decision,” I replied, “and I want to make sure I have a clear idea of how you and Rose want us to take care of you.”

“Condition” became the new idiom for Donny’s undeclared cancer in our lexicon. I recommended that rehospitalization focus on palliation, which would forego any diagnostic testing or treatments for cure. After continuing the conversation, both he and Rose agreed with this care plan, rendering the underlying pathology of Donny’s pleural effusion a permanent mystery.

When I entered Donny’s hospital room, I was surprised to find him sitting in bed and resting comfortably with a chest tube in place. Rose was at his bedside and asked if I could speak with her privately. After we left the room and began to walk the hallways, Rose stopped me.

“How long does he have?” she asked abruptly.

“I don’t think he’ll last two months,” I let slip with no forethought. Rose had caught me off guard and I was upset with myself. The oncologists had told me this timeframe, given his tumor burden and since we were foregoing active treatment. I was worried that my words had extinguished any hope and tried to recover.

“Rose, we are treating his symptoms and making sure that he is comfortable. I mentioned hospice to you both over the phone last week, which provides many services. However, a hospice requirement is that you have to have a family member or close friend as the main caregiver at home.”

She paused for a moment before saying, “Well, Dr Daaleman, I’ll take him home with me, but you know that Donny and I haven’t lived together for 17 years.”

I was stunned with disbelief at this revelation and recalled Donny’s first clinic visit when he was accompanied by Rose and their adult children. The banter and body language between them appeared natural and I never thought to ask further about their married life. In our discussions about Donny’s care, I had envisioned how his dying would play out with Rose. But now, I did not know what to expect.

Four weeks after Donny left the hospital, Rose called me at home.

“He’s gone,” were Rose’s first words as she told me of the events surrounding his death. Despite their years of separation, Rose took Donny back into her home, where the hospice nurses taught her how to care for her estranged and now dying husband. They showed her how to give just the right amount of morphine to ease his shortness of breath. Rose helped him out of a bed that they again shared and was now divided by a mound of sheets arranged so he could rest comfortably on one side. Perhaps it was the daily caregiving that overshadowed Donny’s active dying, since Rose was still coming to terms with the events leading up to his death.

“I’m feeling a little guilty since I dozed off in bed and had the most-sound sleep I had in a long time,” she said. “In my dream, I heard something crash and I thought it was the cat, but it must have been Donny getting up and falling. When I woke up, he was there on the floor, and he must have been gone for some time. I think the good Lord jes’ let me rest.”

I just listened.

“I called the hospice nurse and they came over, and the preacher came over too,” Rose continued. “I was in the living room talking with the hospice folks and my preacher when the people from the funeral home came to the house. They went in to get him and stopped in the living room where we were settin’ to ask if I wanted to see him once more before they took him down to the parlor. I walked over to the stretcher where they had him laid out and pulled the blanket back.”

“As I looked at him lyin’ there, I just blurted out, ‘I love ya, you ole’ son-of-a-bitch!” Rose declared. “Dr Daaleman, I don’t know what came over me,” she said apologetically, “I was so embarrassed, what with the preacher and funeral people all there.”

After Donny died, I would see Rose a few times each year for wheezing that was part of her life. Once we determined that her symptoms were another flare of emphysema, the conversation turned to Donny, with Rose filling in the lacunae of what little I knew about their relationship; his drinking, the infidelities, the emotional and verbal abuse that she put up with. These bits and pieces were always told in a matter-of-fact way, as if this were Rose’s lot in life. At the end of one office visit, I left the exam room incredulous in silent amazement.

“Despite all of this baggage,” I thought to myself, “she still welcomed him back into her home—even into her bed—and cared for him at the end of his life.”

About a year after Donny’s death, I finally got up the nerve to ask Rose the question that had been recurrently on my mind. “Why did you do it?” I said imploringly at the end of the visit. “How could you take Donny back and care for him after all that he put you through?” Rose paused for a moment and looked at me, saying simply, “Because he was one of us; because he was family.” And as she smiled wryly and said this a second time, I saw the face of God gazing at me. Rose’s countenance transcended all my thoughts and emotions with an awareness that none of us can ever be separated; from ourselves, from each other, and from the Greater Reality.

Well before I started caring for Donny and Rose, a former spiritual director encouraged me to describe my image of God during an arid time and place on my interior journey. The activity was challenging since there were no archetypes or figures that resonated or were operative. For several months we continued with this inner work and the only image that I could conjure up was of God as a wise and understanding grandfather-like figure listening to me. It felt forced and inauthentic and I eventually gave up.

As a physician practicing in the shadow of the COVID-19 pandemic, I have been questioning the nature of my relationships with those I care for, and how I think about God or the Greater Reality that is all around. My worldview is no longer optimistic and hopeful, as it was early in my doctoring. Several of my core beliefs about being a physician have been hollowed out, particularly the relevance of my work in the lives of my patients. Perhaps the pervasiveness of uncertainty, separation, and suffering have dried up the wellsprings of my vocation. Or maybe the repeated walling off and compartmentalization of my heart space, which got me through the worst of times, has become a maladaptive response. This isolated practice served me well for years by calming the waters that roiled inside when caring for patients like Donny. Are those waters permanently stilled and stagnant?

More than a decade after this failed spiritual exercise, the face of God was inexplicably revealed to me in an old woman with a focused gaze and a slight smile during an ordinary clinical encounter. Rose died over 5 years ago and I still think about her. When I do, I see a face that is lined with the fullness of life; tears of sorrow and perhaps some joy. As she gazes at me, my uncertainties about doctoring are scattered away with an affirmed reality that we are all “one of us.” And her image draws down and stirs divine wellsprings that are deep in me. If the walls of my fears and doubts can move enough for these waters to flow, I may care for others with fathomless mercy, with love that is sometimes incomprehensible, and with steadfastness that is wearied but never broken.

• Received for publication December 11, 2021.
• Revision received April 7, 2022.
• Accepted for publication May 4, 2022.

• © 2022 Annals of Family Medicine, Inc.