Why I Became a Hospice Psychiatrist

by Mark Ligorski, MD

We think of time as linear and one directional: always moving forward. But there are times in emotional life where we can have reverse echoes. Something from the future reaches back in time to touch us, but we can’t tell what it is until time catches up later on. How could I have known that what I was hearing many years ago when my father was diagnosed with colon cancer was the echo of the work I’m doing now?

A Change of Plans

My father, David, was born in Lodz, Poland in 1922. He was the youngest of 4 brothers and a sister. My grandfather was a devout Jew and a prosperous butcher. All of my uncles went into the family business and my aunt married the son of another prosperous butcher. My grandmother apparently had other plans for my father: he was going to do something different, something special. I was never told what those plans were but they were rendered moot with the Nazi invasion of Poland in 1939.

The Unspoken Years

To escape the advancing German troops, he headed east and crossed into the Soviet Union, in what is current day Belarus. He was hardly alone as there must have been many people fleeing the war. Of course, being Jewish and an undocumented refugee, he was put in prison. You should know that my parents, the rest of my family, and their friends never spoke about what happened during the war years. We kids would have hardly known that a war had taken place, there were so few stories, and they were rarely told in a scary fashion.

When my father did share his recollection of his time in a Soviet prison, he did so in a positive way, detailing how he was locked up with “great Russian intellectuals” from whom he learned a very good Russian. (He also told me that he could speak Uzbek from his time in Tashkent. He could curse in it. I remember the curses; I’ve never had the courage to find out what they really mean.)

After he was released from prison, he went into a work army (chain gang?) and was taken by train around the Soviet Union to work on various projects. Not an easy life, but no one was deliberately trying to kill him.

A New Life Begins

In 1945, the Polish government-in-exile and the Soviet Union signed a treaty allowing all Polish nationals to leave the Soviet Union. My father elected to leave and found his way to a displaced persons (DP) camp near Ulm in Bavaria where he met my mother.

After living in Berlin for several years they finally left Germany in 1950 on the USS General Hersey making their way to New York. Once there, my mother’s cousin helped them adjust to the United States, giving my father his first job in his clothing manufacturing factory.

A Prophecy Comes True

My father, never the kind of guy to work for someone else, left after 6 months to open his own shop. That same perseverance and hard work that helped him survive the war, perhaps coupled with his mother’s prophecy that he was destined for other things, led him to be a successful and prosperous businessman.

This history is important for you to understand the kind of man my father was: hard working, undaunted by hardship or suffering, utterly convinced that his way was always the best way. I never remember him expressing doubt about anything, even when we went out to eat at his favorite Chinese restaurant, the House of Chan on 7^th Avenue in Manhattan. This was back in the days of Cantonese restaurants; they really did have the best Moo Goo Gai Pan in town.

A Steadfast Mind

The problem with this kind of mindset is that when it decides to ignore something, it does it fiercely. When he started having blood in his stool, despite my mother’s concerns, he dismissed it. He was constipated, he said, or had beets for dinner. He was usually right about most things (a begrudging admission on my part after many years. It was tough being a teenager around him with my own opinions.) In this case, however, he was wrong. When he finally came to a diagnosis in the beginning of 1982, his colon cancer had already spread to his liver, and at Stage 4 the prognosis was only two years.

The Secret

The first surgery was performed to remove the tumor that was threatening to block his bowel. That was when the diagnosis was definitively made, along with the discovery of the metastasis to the liver. My mother and sister were frantic that my father not know that the cancer had spread to the liver. It is not clear what they were protecting him from. Given who he was, how did they think he was going to handle that news? I had not been consulted about this decision. I had just graduated medical school and was in a somewhat ambivalent relationship with my family. I would have disagreed with their decision believing he had a right to the information and more than enough strength to handle it. We will never know the truth, whether his surgeon, Dr. Eng, had agreed to not tell him what he had found. But the story goes that after he came out of anesthesia and was in recovery, he asked the surgical resident who told him about the tumor and the liver. My mother is still angry about the acknowledgment and curses that unnamed resident whenever the story comes up.

My father had a second surgery to remove that lobe of the liver where they found the tumor. I don’t think they would have done it today, knowing that once there is a metastasis anywhere there are metastases everywhere.

Echoes, Treatments and Unrequited Gifts  

I am grateful that there was so little to do in those days for my father’s condition, limiting the unnecessary treatments. His surgery was at New York University Hospital but he went for chemotherapy, such as it was, to Memorial Sloan Kettering Hospital. In one of those interesting reverse echoes, my mentor in psychiatry, Dr. Robert Lynn, who had started out as an oncologist, and my father’s oncologist were colleagues. He had nothing good to say about her, and indeed, my parents described her as cold and aloof. In a desire to ingratiate themselves with her, they brought her gifts, believing that she might be more favorably inclined to care for my father because of them. Her attitude didn’t change and the treatment, like the second surgery, didn’t help.

I don’t think the terms “palliative care” or “hospice” were used much in those days, if at all, but they had nothing to do with my father. He was at home being cared for by my mother as he got thinner, weaker, and more jaundiced. There were pain medications for his discomfort. Not a patient man at the best of times, he faced death the way he faced life. He wanted this problem over and done with. I don’t think he was depressed but I think he was annoyed at the physical distress and the indeterminacy of the solution.

Words Go Unheard

We never had an emotionally expressive relationship. His demonstration of care for me was through telling me the “right way” to live my life. I was certainly aware of the distance between us, but had no idea about how to bridge that gap. I was over the house one day talking to him about some of our disagreements. We weren’t arguing but I don’t think we were agreeing either. At one point, overcome with emotion, I said, “I love you.” I had never said it before. Unfortunately, he had nodded off at that moment and didn’t hear me. When he roused himself a couple of moments later and asked what I had said, I couldn’t repeat myself.

The Herald Call

Friday night, July 12, 1984, I was on call as a second year resident in psychiatry. My sister called me concerned that Dad’s breathing was funny. I thought it was the narcotics he was taking for the pain. I told her that I would be there in the morning. After call, my wife, who was 5 months pregnant, and I, drove down to Brooklyn. The Brooklyn of today is a popular place to live where so much is always going on. But, let me reassure you, the Canarsie section of Brooklyn was never cool. It was a nice place to grow up but definitely not hip.

As we turned onto my old block, I saw an ambulance in the street. In a stunning display of denial, I told myself that it wasn’t parked in front of my parents’ home. As we pulled up, the ambulance crew were bringing my father out on a stretcher. What I had thought the night before was a side effect of the medication was really that change of breathing that heralds the end of life.

White Lies

He was still in that rhythm when I drove up. The drivers were about to put him in the ambulance when I introduced myself as Doctor Ligorski and explained my father’s condition. They were very respectful of my title. I hadn’t explained that I was still a resident. This was the beginning of the AIDS crisis, so it was important that they knew that this was end-stage cancer. They also needed to know that there was nothing to do for him in this stage of his illness. They completely understood the situation; they allowed me and my wife, who had been an ICU nurse, to ride in the ambulance to Brookdale Hospital, just a short distance away.

Hard Questions

I have wondered what would have happened if I had gotten there earlier. Could I have allayed my mother’s and sister’s fears? Could I have pointed out the futility of going to the hospital? Was it necessary for them that he go to the hospital to die as opposed to dying at home? This was a negative echo. There had never been any discussion about what the end would look like and what to do. In that lack of discussion, there was no preparation either technically or emotionally. It is strange that despite there being no uncertainty about my father’s condition, the final fact of his dying and death came as a shock.

A Simple Act

We got to the emergency room and I quickly spoke to the admitting resident. I am sorry that I don’t remember his name. Like the ambulance drivers, he completely understood the situation, realized there was nothing to do except to admit him to the hospital and wait for his heart and lungs to catch up with his brain. In an act of supreme compassion, he reached out and squeezed my shoulder. There was so much understanding and loving kindness demonstrated in that simple act that I was almost completely undone.

A Final Gift

Just a few memories stand out of the next several hours until his death. They had misspelled our last name on the door tag, “Ligorsky” instead of “Ligorski.” I had to change it; my father had to die under his proper name. As soon as I got to the floor, I found the intern assigned to my father, asked for the chart, and wrote a note detailing his condition (third time was the charm) and making it explicitly clear that under no circumstances was he to be subjected to any attempt at resuscitation. I don’t know if my note was legal, whether I was even really allowed to write in the chart, but that intern was not going to argue with the “doctor.” Once again, I didn’t let him know that I was just a year or two of ahead of him. I couldn’t tell my father I loved him, but I could offer him this last great gift of letting him die peacefully and calmly, surrounded by his family.

An Ordinary Ending

The last thing I remember was the ordinary nature of the conversations over those last few hours. No one, including my father, was particularly religious or spiritual, so no prayers or profound words were offered. No stories or fond memories were shared, just regular talk about people’s days and activities.

His breathing finally stopped in the late afternoon, easily and softly.

He was buried the next day as is Jewish custom. The rabbi who officiated at the service didn’t know my father. He was only able to say impersonal things about him peppered with generic words of comfort. No one stood up to tell his story, to be a speaker for the dead. This story is one of those reverse echoes finally saying something about him and his final days.

Longing and Mystical Experiences

I didn’t cry when he died and never really did. Over the years, there have been moments of intense longing where I was keenly aware of his absence, especially when confronted with something I think he might have found interesting. I will tell you one kind of mystical experience I had regarding him. I was treating two sisters. They both came from my part of Brooklyn and had been raised in that same kind of semi-secular Jewish way. One of the sisters had become a Born Again Christian. After she died there was a memorial service at her church. I was invited to attend. I came not knowing what to expect. Would I be asked to speak? Would others be asked to testify on behalf of Sister Judy? Pastor Jim Solomon had lovely and moving things to say about Judy. He spoke about the path to Heaven not being paved by good works, which were expected of you anyway, but by one’s devotion to God and Christ.

On the drive home, I felt a sense of unease seemingly related to the fact that I had gone to a Christian church. It was as though my father was complaining. I had brought along a prayer book and a kippah but there had been no opportunity to use them. Pulling the car off to the side of the road, I put on the kippah and recited the Kaddish, the Jewish Prayer for the Dead. After finishing, I looked up, hands upturned and said, “So?” Things were quiet. I guess I had done the right thing by my father.

An Echo Comes Calling

So now I work at Regional Hospice and Home Care, helping individuals and their families deal with the end of life. The work is challenging and rewarding, dealing with raw emotions and inescapable truths. I have been moved by the dedication and devotion of all the people I work with whose mission is to relieve suffering. I am deeply appreciative of the pain and suffering of the people we care for, impressed by their honesty and willingness to open up around their feelings. The echo of this work reaches back in time to my own dad’s illness and death and is a real source of support and validation.

And, by the way, in case I mumble or you are distracted or sleepy, please know, I love you.

Mark Ligorki, MD is the Staff Psychiatrist for Regional Hospice and Home Care. He works with patients, families and staff members as they handle the challenges surrounding the end of life.