Sunday, September 23, 2012

Bert Rettner Joins Dad

My dad’s very close friend, Bert Rettner, passed away today some 15 minutes after my mother visited with him.  Bert often visited my dad in the hospital and was a source of support for my dad during his battle with MCC.

Bert and my dad played great bridge together.  They made an excellent team, and I find comfort in imagining that my dad is right now welcoming Bert and sitting down with him for some hands of bridge.  My dad was a Life Master in bridge.  With Bert’s arrival, I imagine they are now both working toward becoming After-Life Masters in bridge.

Five months out and I still miss my dad every day.  Bert’s passing reminds me that we all end up in the same place – it is not a matter of whether we go there, but when.  Dad loved Johnny Cash, and this passage is particularly poignant: 
Daddy sang bass, 
Mama sang tenor.
Me and little brother would join right in there.
Cause singing seems to help a troubled soul.
One of these days and it won't be long,I'll rejoin them in a song.
I'm gonna join the family circle at the Throne.
Oh, no the circle won't be broken.
By and by, Lord, by and by.

Wednesday, May 2, 2012


Dad changed fundamentally in his two year battle with Merkel Cell Carcinoma.  He discovered the first lesion on May 6, 2010, almost exactly two years ago.  As he came to understand the profound danger he faced, he allowed things that didn't matter to simply fall away.  He got in touch with his love for his family in a way that was far more intense than before he started the battle.  He enjoyed every moment with his grandchildren.  He took his wife on cruise vacations as often as possible.  In the weeks before he passed away, he celebrated a grandchild's birthday and conducted a family Seder.

Dad enjoying Sara's birthday on April 9.

In facing death, dad decided to truly live his life.  I love how he embraced what is important, and allowed the distractions from a happy life to fall by the wayside.  None of us need to wait until we face a terminal illness to live the way dad lived his final years. 

Dad left behind a great family, a family that will live a better life thanks to the legacy and lessons he leaves behind.

Grandma, Poppa, and their five grandchildren on the family cruise, December 2011

Dad and family on a cruise, December 2011

We each remember dad -- and allow that memory to enrich our lives -- in our own way.

His passing allowed me to reflect on whether I was the man he was, or at least the man I wanted to be.  Dad had always loomed large -- a man whose shoes I could never hope to fill.  He was a man who would hoist a canoe over beaver damns, a man who would step in to fix anything that went wrong, a man I turned to for rock solid advice.  He was in so many ways not just a father, but a father figure.  He was a hero to his mother when his father was sick and later died.  He was a hero and role model for his children.  Like any respected father figure, he cast quite a shadow.

Even to the end dad projected strength, regardless of the cancer's weakening of his body.  

A few days after he passed away, I looked in his closet and was drawn to his shoes.  I had always assumed his feet were far bigger than mine, so I had trouble believing what I saw.  I stared for minutes.  His shoes looked the same size as mine.  And they were.  I sat down, picked out a pair of shoes I had seen him wear dozens of times, and put them on.  I literally filled his shoes.

I sat, reflected, and realized that dad may have passed away, but he left his children ready to take on the world.

Dad often listened to the Kingston Trio.  In the days after he died, I found myself tearing up when I played their song "Reverend Mr. Black": 
It's been many years since we had to part. I guess I learned his ways by heart. I can still hear his sermon's ring, down in the valley where he used to sing. I followed him, yes, sir, and I don't regret it and I hope I will always be a credit to his memory 'cause I want you to understand. The Reverend Mr. Black was my old man!

The sun sets during the last family vacation with dad, December 2011


I woke up on Wednesday morning and all seemed well with the world.  I had just spent the weekend in Yosemite, was loving my time with the family, and was enjoying an apparent respite in my dad's illness.

I dropped Eva off at school at 9:00 a.m., and I had Sara and Bel in the car going to preschool.  The phone rang at 9:11 a.m., and it was my mother.  Everybody with a sick relative knows that there are times when your heart drops when the phone rings, but this wasn't one of those times.  I figured she was calling to see if one of the kids wanted to visit after school.  Not so.

Her first words were ominous:  "I didn't want to call you until I was sure you'd dropped Eva off."  My heart drops.  I have a speaker phone in the car, so I warned her that Sara and Bel were in the car and could hear.  I'll never know how the conversation would have gone if she could have spoken freely, but she was fairly blunt:  "Dad is having troubling breathing and we called the pulmonologist but its been a couple of hours and he hasn't called us back. I'm thinking about calling 911 and getting an ambulance."  I told her "hang up right now and call an ambulance, I'll drop off the kids as quickly as I can and I'll get right over to your house."  She did.

At 9:13 a.m. I called my wife and let her know the situation (I'm using the phone records so these are actual times).  I called my mom back at 9:19 to confirm she'd called the ambulance, which she had.  I called and updated my wife at 9:20.

My mom called back at 9:25 a.m. and she told me the back story -- when she woke up and came downstairs, my dad was awake and told her he was in respiratory failure.  I had outfitted his chair with a button connected to a chime that rang upstairs, but he never pressed the chime.  I later confirmed the chime was working and dad was pretty cogent.

At 9:26 I called one brother; at 9:27 I called the other.  I gave them the little information I had.

I was over at the house around 9:30 (I'd stopped at my home, just around the corner, to get my bag and stuff I'd need assuming I'd be at the hospital for a few days).  As I pulled up, the firetruck was there already and the ambulance was parking.  That will make it real in a flash.

I asked if my mom could ride with my dad in the ambulance but they either refused it or discouraged it.  Either way, we drove separate cars.  She wanted to pack some things she would need so I left first.  I followed the ambulance, and their siren and lights weren't on.  I thought that was a positive sign.  I tried to follow the ambulance through the lights, but it turns out that ambulances run an awful lot of very yellow lights, siren or no siren.  I arrived perhaps two minutes after the ambulance, but they had already taken dad into the hospital.  This meant he was on the inside of the impassible doors to the inner emergency room and mom and I were on the outside.  We tried to go in through the ambulance bay doors, but that didn't work.

We walked to the front desk in emergency.  My mom explained that ...

* * *

Ok, that mid-sentence stop above is not typo.  It is an event-driven discontinuity.  I was writing the post during down time before the post-death activities hit a fever pitch.  I don't know if it is designed to distract the survivors or just a mismatch between the things our culture expects and the things the survivors need, but we got so busy with dealing with funeral plans, out of town relatives, condolences, even things like canceling Amazon Subscribe and Save subscriptions that all normal activity slowed to a crawl.  So I continue this post where I left off, my memory both dulled and sharpened by the passage of time.  I wrote the earlier portion of this post well over a week ago.

I sent emails to family all day with updates.  Excepting for things personal to family, I will intersperse this post with those email updates at the time when they were sent.  They are hard to read, even for me (and I wrote them).  But dad never pulled punches.  He was brutally honest.  And Merkel Cell Carcinoma cells are a practiced fraternity of assassins,  operating quickly and brutally.  As my dad documented his transition from vital, healthy 69 year old to an injured but spirited 71 year old with stage 4 cancer, I feel I owe it to him to document the final part of that transition, the one that ended with his release from a pained and infested body.  He asked me to post about what his last day was like, and I feel my contemporaneous emails perhaps best capture the type of chaotic uncertainty that others facing MCC (and their families) should prepare for.  I hope it is wasted preparation and a cure is soon found, but this is here as a resource while we await the success of the work of Dr. Ngheim and others.

Contemporaneous posts are found in courier text in a quotation box, prefaced with "Email".  The first of them is immediately below this box.  Note that the subject line tried to keep format of "Update" with 24 hour time following.  I didn't keep that up the whole time.

** Email sent Date: Wed, 18 Apr 2012 10:07:59 -0700
subject: "Update 10:06"
He has arrived by ambulance. He is in the ambulance bay. We are not yet allowed to go back to see him. We expect the go in a few minutes. Will then be more to let you know. Sent from my iPhone **
** Email sent Date: Wed, 18 Apr 2012 10:24:02 -0700
subject "Dad"
Just arrived via ambulance to st Agnes. Irregular heart rate andrhythm. Low spO2. Did [SIC, should be did not] feel he could tolerate car ride to hospital.More if there is more. Please share with his siblings. 
Sent from my iPhone **

We walked to the front desk in emergency.  My mom explained that her husband had been taken in by ambulance and was in self-described respiratory failure.  The man staffing the desk seemed like he wanted to be helpful but was overwhelmed with responsibilities (emergency rooms, even on a weekday, are partly emergencies and partly primary care for the uninsured, so the front desk staffer is the front line recipient of a lot of angst and conflict).  When he said, more or less, that they had things well in hand back there and we'd be called in at some point later, I felt something in me that happens once every few years.  The last time it happened was during the 2008 presidential campaign when I was managing a voter registration drive and we were illegally instructed by law enforcement that we weren't allowed to register voters in a public place:  I flipped into intense, personally impacted lawyer mode.  I felt myself compelled to stare, unblinking, into his eyes and say "understand that my mom has been married to him for 50 years.  He worked at this hospital for decades.  He is a doctor and thinks he's in respiratory failure.  I need you to go back there, tell them that, and tell them that the family refuses to let him die alone and we need to be let back there."  I'm normally pretty non-confrontational (at least in person), but if the intensity of my words were translated into physical force, the guy would have been unconscious on the floor.  He said, basically, "take a seat, I'll let them know."

We sat down and I watched him rush back to the inner sanctum of the ER.  When he returned to the desk my mom went up to follow up.  I don't know what she said, but she came up to me with a badge on and said that they could only get one visitor badge.  I told her to head in.

** Email sent Date: Wed, 18 Apr 2012 10:50:22 -0700
Subject: Update 10:44 am
Mom is in there with dad. I'm in waiting room due to "one visitor at a time policy".
He's confirmed to be in atrial fibrillation. He is already on amioderone, which is the drug that previously fixed it, so I assume they're going to up the dose or use something in addition.
They hear a wheezy noise they don't like in his lungs. They are taking him in for a chest x-ray. Obvious candidate is pneumonia (fits with with low blood oxygenation level), but given the cancer impinging on the bronchi, who knows. Mom thinks (hopes?) they'll let me in after the x-ray. I think dad is more comfortable having his wife with him, so I encouraged her to stay by her side and that I'd be fine patiently waiting in the waiting room. I didn't tell her about the very loud annoying woman eating something on the order of 40 pounds of Fritos who is sitting next to me, but she doesn't need to know everything.
My guess is that they'll admit him at least overnight, if for no other reason than defensive medicine to avoid a lawsuit if they release him and he has a fatal heart attack. But no decision has yet been announced on admission.
I think it is a bad sign that I've gotten good at this. I have my laptop, my TOR browser (to get around the hospital filters), my iPad with hotspot (in case Tor fails) and my iPhone with megacharger. I also have meal replacement drinks with me.
I should create a macro for the term "this sucks", since I'm writing it a lot. This sucks.
More when there is more to share. **

Mom came out a few minutes later and said dad was still ok and cogent, but they hear something they don't like in his lungs and he's going for a chest x-ray.  She wanted to know if I wanted a turn in there.  I said no, you're his wife and I know he wants nobody more at his side right now.  She just nodded and headed back in.  In a different world, my mom would have been a lawyer, because within a few minutes she appeared in the waiting room with a second badge, saying something about how she insisted that the doctor issue one for me.  And with that, we were both able to get back to the ER back area.

We had some time waiting for x-ray and dad called me over.  he said something to the effect of "If I don't make it today, I want you to make sure to update my blog with what happened."  Until that point, I thought the blog was partially cathartic for him, and partially an effort to help others battle not just MCC, but the weird, scary, unexpected things that accompany it.  When facing his own death and knowing that he wouldn't get to enjoy the catharsis of writing about it, I learned that (at least by the end) he was providing his fellow travelers down the "life with MCC" path with the kindness and protection of the type he had spent 50 years providing his family (68 if you count protecting his siblings).  I promised him I would keep the group updated.

Dad was, by now, switching between being very aware and closing his eyes.  During the first eye close following that discussion, I quickly updated the blog with the current situation and sent an email:

** Email Date: Wed, 18 Apr 2012 10:59:01 -0700
Subject: docdave back at hospital
To: [ mcc google group ]
New update, dad is back in the hospital. **

We immediately started getting supportive messages back from the MCC group.  At moments like this, every message of support is worth ten messages of support during more stable times.  They were all read and appreciated.

My mom was shaky and hungry, and was worried about taking the time to go to the cafeteria.  I remembered from the prior hospitalization (you don't want to do this enough to know how to work the system like this) that nurses will bring family a plain but sufficient sandwich if you ask nicely.  I tracked down a nurse and my mom was spared the anxiety of being away from dad (and he was spared the anxiety of being away from her).  She did need to go to the restroom, though, and I took that opportunity to tell my dad that whatever happened, he had good sons and we would make sure mom got all the support and looking after that she needed.  He visibly relaxed.  He knew it, of course, but it is important to say it, particularly when somebody is experiencing poor concentration or high pain.

Another thing that happens in these situations is that you seek a tiny bit of normal in the day.  Perhaps it keeps you moored.  I emailed the local camera shop and asked what kind of lenses they rent.  I know, the very strangest thing you might imagine doing.  But dad had his eyes closed, mom was deep in thought, and I needed to remind myself that life would go on regardless of the outcome.  You will be tempted to feel guilt over such moments.  Don't.  I took a few such moments, and they gave me the strength to be well moored when the time came for the really hard stuff.

At some point that day, the Votrient we had ordered via next day delivery was to be delivered to his home.  His final post was made just days before he died:  “it looks like Topotican did me no good….  I have had respiratory difficulties … [and when I] attempted to go upstairs for a shower … that was a failure as I had [an] asthma-like attack.  It looks like I have a choice of waiting to die or going on Votrient … I somehow doubt my insurance will pay and I think it will cost a lot of money….  This seems to be the last arrow in my quiver.”  He wasn't home to sign for that first shipment of Votrient because he was in the hospital, dying.  Dad was a realist, but a fighter -- he was ordering ammunition to use against the cancer the day before he succumbed to it.

We were still waiting for the x-ray at 11:46.  We were getting impatient, but they wanted to stabilize his heart first.  First things first, I guess.  I'm not a doctor, but it didn't seem to surprise my dad, who was a doctor.

I realized I hadn't been keeping my ex-wife (and oldest daughter's mom) up to date.  I emailed her along with my brothers:

** Email: Date: Wed, 18 Apr 2012 11:46:50 -0700
Subject: FYI
Dad is alive, alert, and describes himself as restless. They won't X-ray him until they stabilize his heart. spO2 is ranging 88% to 92%. Pulse 120. Blood pressure scares me at 90/38.
He expects to be admitted overnight.
Sent from my iPhone **

My ex-wife wrote back "Thank G-d!" when learning my dad was alive and alert.  Divorces are tough on families and there is a temptation to demonize the ex.  My dad never gave in to that temptation, and was probably the most even-tempered of the lot of us during that time.  I've previously posted about the benefits of a happy blended family, and this was one of them:  My ex-wife stood by the ready to help, and when my dad died, she was able not just to comfort our daughter, but to comfort her from a place of empathy.

Turns out I read the blood pressure wrong.  There will be errors, and when reporting to remote family members correcting the errors quickly is pretty important:

** Email: Date: Wed, 18 Apr 2012 11:50:49 -0700
Subject: Re: Update 11:43
Correction. I misread blood pressure. 113/47
Sent from my iPhone **

In retrospect, I'm not sure that I misread the blood pressure, since it kept swinging pretty widely, but in the moment I wanted it to be 113/47 more than 90/38, so when I saw that reading, I was pretty willing to assume an error rather than volatility.

I told the nurse that we wanted dad to speak with the doctor directly about his instructions regarding "do not resuscitate" ("DNR") and similar issues.  The nurse said she would get the doctor.

By noon, I was starting to feel a real risk that dad wouldn't make it out of the hospital.  On the one hand, I was thinking they might send him to a regular room, but in my gut I was worried he wouldn't even make it to the ICU.  I didn't want my out of town family to be caught by surprise (more than they already would be) by getting "he's at the hospital" emails followed by a "he passed away" email.  So I sent an email offering a pretty frank assessment:

** Email: Date: Wed, 18 Apr 2012 12:03:49 -0700
Subject: Re: Update 1201
O2 saturation took a nosedive before recovering.
Dad is kind of out of it on and off.
I'm not an MD so my intuition means little scientifically, but I have a very bad feeling in my gut about this one.
Sent from my iPhone **

The emails are, by now, getting harder and harder to send, but I'm getting to the point where I am getting teary-eyed and I fear having a phone conversation would be a very hard thing to do without becoming incoherent.  So emails it was.

We got word that the ER doctor wanted to admit him to the ICU, but they first whisked him off to x-ray.
** Email: Date: Wed, 18 Apr 2012 12:07:28 -0700
Subject: Re: Update 1206
On his way to X-ray.
ER doctor wants him admitted to ICU. we'll see if there is an available bed. **
The doctor came in and I asked him to ask my dad for his specific DNR and related instructions.  I was aware that my mom and I knew them, but I knew they would be followed more accurately if given directly by the patient.  It also would save my mom, if it came down to it, from having to say the words that dad would have wanted her to say but that would be very hard to actually say with regard to somebody she's loved for over 50 years.  I also recognize that writing instructions in a lawyer's office, or even discussing them in the abstract even in a hospital bed, is only a simulation.  When faced with the reality that the instructions are likely to actually be followed that day, people often need to tweak their instructions.

He said he did not want to be resuscitated "ever", regardless of the event or the severity of the event.  I got him to clarify whether he would want to be resuscitated even in the event of a minor event, and he said "no" with clarity and purpose.

** Email: Date: Wed, 18 Apr 2012 12:31:43 -0700
Subject: Update 12:28
He has been admitted to ICU.
he just gave the doctor an order that he does not want to be resuscitated "ever" regardless of the event, respiratory, cardiac or otherwise. So given he has abnormal cardiac rhythm, terrible O2 sat, probably needs to be intimated [SIC, should be intubated], and has tumor impinging his lung, the DNR instruction gives a very high risk of death in the next few hours or days. A hope I'm wrong.
Sent from my iPhone **
The x-ray came back around 12:15.  I don't recall dad reading it himself, it is one of the few memories that aren't still totally clear for me:

** Email: Date: Wed, 18 Apr 2012 12:22:16 -0700
Subject: Update 12:20
Dad read his own chest X-ray. Described it as bad, bilateral pneumonia.
I'd be shocked if he isn't in the ICU overnight.
Sent from my iPhone **

My dad was visited by the doctor who was to admit him to the ICU.  I prompted this doctor to make sure he knew my dad's wishes, and to ask my dad directly.  He did:

** Email: Date: Wed, 18 Apr 2012 12:58:57 -0700
Subject: Re: Update 12:58 bad news. Possible rapid development.
He just refused intubation. He instructed doctor "instead of intubating me, just shut me down with morphine. I've just about had it. I've had enough."
He is giving instructions that make it highly likely he will not live much longer.
He is peaceful, tired, kind, and entirely unemotional.
Sent from my iPhone **

I was getting a lot more anxious.  My mom was getting anxious as well, although both of us began to feel an increasing split between the reality unfolding in front of us and the reality as we wished it were.  Dad was clearly preparing to die, and that was the objective reality.  The analytical Harvard-trained lawyer knew this, and he was the one drafting the emails.  The scared little boy watching his daddy suffer, watching his hero lose his last battle, watching his role model pass in and out of consciousness, that scared little boy believed that his daddy would make it.  That scared little boy knew nothing could beat his daddy, his protector.

Ultimately, both the lawyer and the scared little boy in me were right.  Dad was dying, but he was dying on his terms.  Merkel Cell Carcinoma wanted to torture him into the darkness, to chase him scared into the wildness of death.  He stood his ground as long as he could, then metaphorically said "fuck you, cancer, I may not be able to stop you from hastening my death, but I'll be damned if I let you dictate how, when, and with what degree of pain."  Dad was a doctor, and a good one at that.  He knew he had pneumonia, and he was bringing up morphine, a respiratory depressant (like hydromorphone, trade name Dilaudid).  He was unable to dictate the terms of his entry to the world of cancer, but he had just laid out the path for his exit.  There would be no horrific final days of pain and suffering.

My brother Michael wrote back at 1:36 (4:36 in Philadelphia, where he lives) "I wish him good luck.  Bon voyage, dad.  I love you."  Reading that, from my youngest brother, made things even more real.  We were really all saying our goodbyes.  The rational part of my brain was holding out hope even as I knew hope was fading fast.

They were ready to move him to the ICU, they had his room, but the doctor with the paperwork was busy with another patient.  We waited quite a while before he was moved.

** Email: Date: Wed, 18 Apr 2012 13:46:13 -0700
Subject: Update 13:46
Dad about to be moved to ICU 12 on the B side
Sent from my iPhone **

Before they moved him, they wanted to do something about his oxygen saturation.  It turns out that while he refused intubation, he accepted a "BiPAP" mask.  This is a mask that covers the nose and mouth and when it detects the patient breathing in, it ramps up the pressure to force in the air.  It also allows oxygen to be intermixed with the air, up to 100% oxygen.  My guess is that dad knew dying from pneumonia would be horribly painful, emulating drowning in some ways.  The BiPAP mask may have been his way to avoid some of that pain.  Unfortunately, it had two huge drawbacks.  First, dad's glasses wouldn't fit with the BiPAP mask on.  He had trifocals, and while I could get them in place, they were slightly off in height, just enough to be non-functional.  I later learned that they could have fit the BiPAP mask around the glasses (although I asked about it at the time and was told no).  Later that day I would rush out briefly to pick up my medications (in case I had to stay overnight a few nights), my dad's PEG tube feeding food (he never used it), some stuff for my mom, and materials to modify his glasses to fit the BiPAP mask.  He never did wear his glasses again -- by the time I had the materials to modify the glasses, he never got to the point where he was interested in wearing them.

The thing I think he didn't consider about the BiPAP mask is that it is like a mini hurricane when the patient tries to lift the mask to talk.  If the patient doesn't lift the mask, the sounds are muffled. So once they fitted him with the mask, there would be no intimate whispers, no final lengthy conversations.  Communications reduced to signs, words, sometimes sentences.  We, of course, talked with him a lot.  His inability to respond was probably more frustrating to him than anybody else.  He couldn't see clearly or talk clearly due to the BiPAP mask.  Layered on top of the hearing loss from the earlier chemo round, he was limited in his interactions with the world.  Perhaps it was how he wanted it.  He started to close his eyes more often, and at times he looked like he was dreaming peacefully.  My heart imagines him dreaming of good days during those moments.

They finally took dad to the ICU.  This marked the second time my mom and I were forced to spend time away from dad.  We followed his bed to the ICU, but they stopped us at the door and said they needed to be alone with him to get him set up and do the intake.  We waited in the ICU waiting room.  The ICU waiting room was decorated with borderline-depressing images so bland they were probably unnoticed by the others in the room.  The television was blaring with an A&E show about a bounty hunter.  Mom and I sat next to each other.  We were told we would be called back soon, but it took nearly 45 minutes.  Ultimately, we got back in by following a nurse through the doors.  Not following protocol, but nobody complained.

When we got in, I introduced myself to the nurse and asked the questions I had learned to ask during the last stay.  The first question -- did he get Dilaudid yet?  Yes.  In better times, dad wasn't a big drinker and didn't use painkillers in a serious way.  In fact, he often ignored his Vicodin prescription during the weeks leading to this day in favor of a simple Advil.  So he was very sensitive to painkillers.  And he'd asked for more than he usually asked for during his prior hospital stay.  A smart doctor, in respiratory distress, very responsive to low dose Dilaudid, yet receiving a higher dose than normal.  He wasn't going to suffer on the way out, and cancer wasn't going to get extra days of artificial life support during which it could torment him.

Soon they wheeled dad out for a CT scan and again banished us to the ICU waiting room.  They again took a long time before letting us in to see him.  I suspect he was instructing the nursing staff at this point and wanted privacy to give some blunt instructions to them.

** Email: Date: Wed, 18 Apr 2012 17:11:24 -0700
Subject: Ct done
Dad just got back from ct scan. They wont yet let us in to see him. No real news for the moment but hopefully know more soon
Sent from my iPhone **
We were in no mood to remain banished to the waiting room, so we were appreciative when the cardiologist came by, got us from the waiting room, and took us into the ICU so we could participate in the conversation with dad.

As I wrote two months ago, during dad's past hospitalization, around 2:30 a.m. one night he developed a sinus tachycardia of around 120 beats per minute, and around 3:00 a.m. the nurse came in and said he had developed atrial fibrillation at around 140 beats per minute.  When he heard that, he said "oh shit".  On that night, the atrial fibrillation scared him, because he held out hope of beating the cancer, or at least delaying death, and he was starting to feel physically better.  He was right, by the way.  He had some good times after that night, cancer be damned.

This night was different than that night in a key way:  The cardiologist took us in, and told him that he was experiencing not just atrial fibrillation, but atrial flutter.  The top of dad's heart was beating around 300 times a minute, but only about 1/3 to 2/3 of those impulses were being transmitted to the bottom of his heart.  This time, dad didn't say "oh shit".  In fact, he had little reaction at all.  His body had already told him more than the cardiologist ever could.  I again recited my understanding of dad's DNR instructions in front of dad and the cardiologist, and made sure that everybody understood his wishes.

** Email: Date: Wed, 18 Apr 2012 17:34:48 -0700
Subject: Update 17:27
No ct results yet
The cardiologist was just in. He said the prognosis was bad. He apologized for not having "anything good" to tell us.
The top of dads heart is beating around 300 times a minute. About 1/3 to 2/3 of the electrical beat signals do not get transmitted to bottom of the heart, and they're trying to reduce that number. He says this condition doesn't usually yield cardiac arrest. The bigger problem he says is no oxygen from the lungs. Without oxygen "nothing works". So cardiologist is quite pessimistic.
My subjective evaluation of his appearance and affect is also pessimistic.
Mom and I are both having trouble seeking a path that ends with him going home, but of course we're hoping.
Sent from my iPhone **
The medications dad needed to stabilize his heart were too much for his chemo-weakened veins.  They had nothing but trouble putting in IV lines during dad's prior hospitalization, and this time they needed to put some medication in that was not well suited to a regular IV anyhow.  They wanted to put in a central line (an IV that goes directly into a very large blood vessel, in this case a subclavian central line).  He appeared to consent, but the nurse was no longer sure that dad was sufficiently alert to consent.  Mom and I knew dad better than the nurse, of course, and we were able to see that he was sufficiently cogent to consent.  Mom said to do it.  Interestingly, dad then engaged in a conversation (such as he could, pulling the BiPAP mask to the side) asking the nurse about the preferred placement of the central line.  The nurse's concern regarding dad's ability to consent was not without basis, however.  He was periodically losing concentration, with his eyes rolling up or closing.

** Email: Date: Wed, 18 Apr 2012 17:56:06 -0700
Subject: Re: Update 17:27
They are putting an emergency central line in. We are being sent out since it is a sterile procedure. Nurse refuses to accept dads consent because he's too sick and out of it. She is looking to mom for consent.
They won't say it out loud, but he's crashing.
Sent from my iPhone **
Blood oxygen saturation.  It seems like a rather arcane thing, but it turns out to be critical in situations like this.  The math is pretty simple -- if there is enough oxygen in your blood, your brain and body work.  As the oxygen level drops, your brain stops working right and your body takes measures to protect the organs and brain.  Dad's blood pressure and pulse, combined with the increasing chill in his extremities, made it nearly impossible to get an accurate blood oxygen (SpO2) reading.  The pulse oximeter stopped working on his left hand fingers.  They tried the right hand fingers, but no luck.  I suggested his toes, since the socks were keeping his toes warm, but that worked only for a minute or two.  They tried his ear lobe.  Ultimately, they fitted him with a special SpO2 measurement device that read from the forehead.  Since we were non-doctors, our focus was only on the machine readings we knew to be significant -- pulse, blood pressure, and SpO2.  I was relieved to have the SpO2 reading available again, but it was dropping steadily and that was pretty distressing.  I don't remember quite when in the sequence of all these things that the pulse oximeter stopped working, but it seems like it was around here, give or take an hour.

The CT scan results were back and they were not good.  The doctor took us back to the computer, spent some time logging in, and then walked us through the results.  I've looked over my dad's shoulder at the x-rays and CT scans he would read since I was old enough to look over his shoulder, and I never quite figured out how he saw what mattered in those images.  Just like my dad would sometimes do, the doctor walked us through my dad's CT results.

I know that MCC is a terrible cancer, but at that moment it seemed to be possessed of a primal malevolent intelligence, and decided that if dad was going to rob it if the ability to inflict more pain, it would at least make his death as frustrating, inflicting one last round of bad luck or even irony. Dad's left lung wasn't sick.  It showed some possible signs of slight pneumonia, but was in pretty good shape.  It would be able to get plenty of oxygen to his brain and body -- if only the Merkel Cell Carcinoma had not wrapped itself around the left bronchial branch and squeezed it shut.  The right bronchial branch was wide open, easy airflow in and out, and would be able to get plenty of oxygen to his brain and body -- if only it wasn't filled with fluid from pneumonia.  So MCC left him with a functioning lung he couldn't use, and a compromised lung he could use.  His SpO2 kept falling, and now we knew why.

** Email: Date: Wed, 18 Apr 2012 18:29:33 -0700
Subject: Ct results
Left lung better than right, pretty clear but left bronchial branch is totally blocked so he can't use that lung tissue. Right ling quite bad, lots of infection but open bronchi. They may insert left bronchial stent tomorrow. Central line going in now.
Sent from my iPhone **
Dad had refused intubation but said (in very brief words due to the BiPAP mask) that he would consent to a bronchial stent.  Such a stent would open up his left lung.  I'm still not sure why a stent wasn't put in on an emergency basis.  My non-medical guess is that with his heart in atrial flutter, they didn't think the additional anesthetic would be tolerated -- but I really don't know.  I don't even know if he was still in atrial flutter.

At this point, they were approaching a shift change.  The ICU nurses work 12 hour shifts, and they usually kick out family members for an hour around shift change so that the outgoing shift and properly brief the incoming shift.  I really didn't want dad to be alone at this point, and was starting to worry about how I would deal with the shift change "please leave for a bit" request. They required us to leave because they needed to create a sterile environment so they could put in the central line.  That took care of the question of whether I would object to having to leave during the shift change.  We were again banished to the ICU waiting room.

I took the forced time away from dad as an opportunity to pull out my laptop and update dad's blog.  I wrote "He seems to be cogent, at peace, and just wants to stop hurting."

** Email: Date: Wed, 18 Apr 2012 18:47:17 -0700
Subject: Another post, doc dave doing worse
To: [Merkel Cell Google Group] **
** Email: Date: Wed, 18 Apr 2012 18:48:30 -0700
Subject: Another post, doing worse
To: [Large bcc list of Dad's friends and relatives]
This has already been a long day. Going to be a long week no matter howtonight turns out. **

Soon enough the doctor came and told us the procedure went well. We were briefly allowed into the ICU and then kicked out so that they could x-ray dad to confirm the placement of the central line.

Mom was starving and agonized over whether to get food downstairs.  The x-ray was clearly going to take more than a couple of minutes.  We asked around and going downstairs to the cafeteria was the only option.  Although she ran down and was back with food in minutes, I regret not insisting that I pick up food for her.  For a day filled with hard decisions and intense stress, it was one of the few things I think I should have known, at the time, to do differently.

In the meantime, the room had cleared out and I took the opportunity to change the blaring waiting room TV channel to something I could ignore and turn the volume down to a level just loud enough that others would not feel the need to turn it up if they wanted to listen.  I originally wanted to turn it off, but I was sure it would just get turned back on and then the person turning it on would of course crank up the volume.  I wanted time with my thoughts.

** Email: Date: Wed, 18 Apr 2012 19:21:05 -0700
Subject: Re: Ct results
Central line went in OK. They kicked us out (again) so they could xray him to confirm that the line was placed properly.
His breathing is really labored. He is also getting serious discomfort with the BPAP [SIC should be BiPAP] mask. The doctor ordered another dose of hydromorphone with the goal not of eliminating pain but of relaxing dad enough so that he can allow the machine to breathe for him. Mom went to get dinner. She's rattled but seems to have accepted things are serious. **
They finally let us back in.  We met the night shift nurse, and I was glad we had a nurse who seemed competent and caring.  The oxygen level in dad's blood was dropping, and the nurse bumped the oxygen percentage in the BiPAP mask up to 75%.  He mentioned that because dad didn't want to be intubated, once the oxygen percentage went to 100%, we would be out of options to bring up dad's SpO2.

I again went over the DNR orders with the nurse during one of the periods when dad was cogent.  He told the nurse "I don't want you to code me under any circumstances."  This was apparently hospital shorthand for calling a code blue and trying to resuscitate him.

Dad was working pretty hard to breathe, and the nurse would periodically speak his name quite loudly to make sure that he could be awakened.

I told dad I loved him, and that his granddaughter had asked me to tell him that she loved him.  My mom told dad she loved him.  I kissed him on the forehead.

I told the nurse that dad is a doctor, mom has spent 50 years married to a doctor, and I grew up in a doctor's family -- and we wanted him to not dumb down or soften the truth.  My mom suggested we have that discussion outside.  We walked outside, and I bluntly asked the nurse about whether I should go home.  Basically, I told him that I knew it wasn't the kind of thing he could give accurate percentages for, but I was trying to figure out if it was more than 20% likely dad would pass away that night.  If it was less than about 1 in 5, I would go home so that my mom could stay with him overnight and I could be with him the next day (I didn't want us to both be up for 24 hours, both fall asleep at the same time, and have my dad pass away then -- so the question was whether it was appropriate for us to keep him company in shifts).  The nurse said that he had seen patients in my dad's condition recover, but he'd also seen them decline very quickly and pass away.  He thought dad would probably make it through the night, but there was a real chance he wouldn't.  He then said that in my shoes, he wouldn't go home.  I thanked him then for his blunt advice, and I thank him now.  Mom was also weighing taking shifts, but at this point we were both expecting to be there all night.

** Email: Date: Wed, 18 Apr 2012 20:36:41 -0700
Subject: Update 20:33
He has central line and foley catheter. He is working extremely hard to breathe.
I spoke with the nurse outside the room and told him I didn't want to go home and have my dad die while I'm home. He said in that case I should not go home. He said he didn't think it more likely than not that dad dies tonight but that it wasn't a remote risk either.
Sent from my iPhone **
At some point, the nurse sought clarification of the DNR orders.  He said that he understood my dad did not want to be intubated or resuscitated, but suggested that if his heart went into a bad rhythm, he "could be paddled" back into a normal rhythm.  He asked my mom what she thought, as she was the person with the final word when my dad couldn't consent.  I waited for a while, but I saw in her eyes that she knew my dad's answer was "no" but that it was too hard to say that about somebody she loved so much.  I'm sure she would have eventually said it, but I stepped in and said "my understanding is that dad wouldn't want that, isn't that right mom?"  She just nodded her head in agreement.

My dad's SpO2 kept dropping, and the nurse increased his BiPAP oxygen to 100%.  The SpO2 continued to drop.  Some time around 9:30 dad stopped responding to the nurse with anything but perfunctory acknowledgments, and by 10:00 he was not responding at all.  The nurse squeezed a muscle on his upper shoulder as hard as he could, yelled "Dr. Shuster" several times, asked dad to squeeze his finger, blink or open his eyes, but there was no response.

At this point, I was regularly streaming tears.  My mom warned me about her propensity to faint in really seriously bad situations -- I'd spend the night looking out for that.

** Email: Date: Wed, 18 Apr 2012 22:09:13 -0700
Subject: 22:07
Unconscious. Unable to awaken him. Non responsive. No longer BPAP [SIC should be BiPAP] candidate per nurse. Nurse says death may be imminent.
Sent from my iPhone **
 My dad's left arm had the IV and a bunch of other stuff attached.  His right arm was clear.  Mom was sitting on his left and I was sitting on his right.  I said something like "you're his wife -- would you like to switch places so you can hold him skin to skin without all this medical stuff in the way?"  She started to amble around the bed, but stopped at the foot of the bed.  She grabbed his feet and said "no, you stay there.  I'm going to rub his feet.  He always loved when I rubbed his feet."  So there we were, me silently crying, holding his hand and arm, my mom with a sad, fixed determination, rubbing his feet and deep in thought.

** Email: Date: Wed, 18 Apr 2012 22:17:22 -0700
Subject: Re: 22:07
The nurse just brought Kleenex. So the nurse thinks we're at the about to need Kleenex phase.
Mom says she is near vomiting.
Sent from my iPhone **
My brother Michael responded almost instantly with an email "Me too.  Its late here, but sleep isn't happening."

I was fighting to strike a balance between feeling my emotions and retaining enough control to be there for my dad and my mom.

The nurse observed the skin on dad's head and said that it had taken on a distinctive look that often is associated with impending death.  I have no idea if that is a documented medical thing or just the nurse's experience, but he was right.

It is worth observing that from the time that dad lost consciousness, he had a look on his face that was really peaceful.  He had a look that was entirely consonant with his remembering the great times in his life, running down the beach with his wife, enjoying family birthdays, all good stuff.  His body may have been shutting down, but he wasn't suffering.  He sure looked like his consciousness was in a good place, a place the pain couldn't reach but where the good memories were easily found.

The nurse said "it's happening".  I was holding dad's hand.  I looked up at the EKG machine and saw a single, final heartbeat and then a flat line.  I looked back at dad.  I said "I love you, dad" and leaned in and kissed him on the forehead.  After some time (seconds? a couple minutes?) I stood up, tears running down my cheeks, and walked over to my mom, who was sitting on a chair against the wall, a few feet from the foot of the bed.  I hugged her and asked "mom, what can I do here, what do you need?"  My said, in a voice I'd never heard her use before, "tell them to get all that stuff off of him so I can hug him one last time."

I walked to the nurse and told him, my words by now interspersed with sounds of crying.  The nurse said he was on it, and within seconds my dad's body was clear of all of the medical equipment.  She held him.  I described what I observed in my eulogy, and the written version is part of this blog as a separate post.  This post is about my dad's last day of life, and sadly he died at 10:55 p.m.

This isn't the kind of news you can deliver to your wife or brothers by email, so I called them.  I called my youngest brother first, since it was the middle of the night there already.  My phone bill shows it was a 3 minute call, and I'm sure I spent the first two minutes of that just sobbing, unable to say the words he knew were coming.  The remainder of the calls were more cogent but no easier to make.  Finally, I let dad's online family of fellow MCC fighters know the bad news.
** Email: Date: Wed, 18 Apr 2012 23:13:51 -0700
Subject: docdave passed away
To: [Merkel Cell Cancer Google Group]
Will be a blog post after I get my thoughts together. He died 10:55 pm **
Dr. Nghiem played a critical role in dad's care, and while I focused strongly on family in the days and weeks following dad's death, I wrote Dr. Nghiem first thing in the morning the day after my dad's passing:
** Email: Date: Thu, 19 Apr 2012 08:16:56 -0700
Subject: Dave Shuster
From: Gary Shuster []
To: Paul Nghiem []
Dr. Nghiem
Thank you so much for the support you provided my dad. He died last night. Some people would like to make donations to MCC research in his name. Could you please provide me with the information I need to put into obituaries to instruct people as to how to make those donations?
Again, thank you for what you did for him. I don't think anything could have extended his life beyond the years he had, but thanks to you the treatments he underwent were not the debilitating and ultimately unhelpful ones such as a radical neck dissection. Thanks to that, he was able to take many cruises and vacations and enjoy birthdays with his grandkids. **
 His response, as always, was prompt and written from the heart.
** Email: Subject: Re: Dave Shuster
From: Paul Nghiem []
Date: Thu, 19 Apr 2012 09:36:39 -0700
To: Gary Shuster []
Dear Gary,
I am so sorry for your loss.
It was a pleasure and an honor to take care of your Dad & to follow his remarkable journey/battle as chronicled by such a humanistic, articulate physician.
Thank you for thinking of others with MCC at this time regarding donations in honor of your Father.
Relevant information is below, and can be obtained directly via:
Paul Nghiem **

I made many promises to my dad on his final day, but three stood out.  First, I promised to make sure the medical staff would honor his wishes with regard to treatment, and they did.  Second, I promised to make sure I would be there for mom, and it is a promise I carry with me, and intend to keep for the remainder of her life.  Third, I promised to document his last day for his blog.

This extremely lengthy post attempts to keep that last promise.  I know that dad understood the cathartic nature of posting to the blog, and at some point writing this entry, I realized I was as much keeping my promise to him as I was helping myself to understand the enormity of that day.  I suspect the promise to update his blog was intended not just to make sure the ending of his story was told, but to help his eldest son heal in the telling of it. It was as much a gift to me as a promise to him.

We spent weeks together in the hospital, and there was little left unsaid between us.  I loved him as a father.  I loved him as a friend.  I will miss him.

I sign this post using the same Jewish nomenclature I used when I signed the memorial book at his funeral:

Gary, son of David; Gershon ben David


I wrote the following as the eulogy I intended to deliver at dad's funeral.  I ended up delivering a somewhat different version (the reality of speaking at a funeral is that it is a rare person who delivers written remarks without giving in to emotionally-driven spontaneous changes).
* * *

I am planning to cry, so please bear with me if I need a minute during this.

I’ve given eulogies before, but I’ve stuck with facts, praise, and prose.  Dad deserves that kind of praise and prose, and he’ll get it from me and others.  But I had the privilege of spending weeks living with him in the hospital, switching nights with my mom, and helping him as he did thing after thing for the very last time.  It was hard to watch him suffer, but I am grateful I was able to give him the gift of companionship, the gift of making sure the hospital followed his wishes, and to enjoy the gift we gave each other of leaving nothing unsaid between us.  So instead of talking about how great a dad he was – and he was, and you’ll hear that over and over today –  and instead of offering a biography, I want to share his last moments with you.

I’m coming to grips with the fact my grandfather was the patriarch of the family just five years ago, dad was the patriarch until Wednesday, and that role now rests with me.  But that also means that dad isn’t 71 years old anymore.  He isn’t old, or sick, or worried, or battling cancer.  I see him reflected, as if he were still alive, in the things my daughters do day to day, in my brothers’ kindness, in my mother, and frankly in my drive to do the right thing no matter the personal cost – particularly when the right thing involves keeping my family happy and safe.

We die as we live, and his last day told the story of his life. 

He lived as a strong man, a man who knew what he wanted.  On his last day, he knew he was going to die, and he didn’t want to suffer.  In the morning, he told mom he was in respiratory failure, and she called for an ambulance.  As he left his home for the last time, even struggling to breathe, he was having a technical discussion with the paramedics about his condition, he liked the details of stuff and he loved medicine. 

Mom and I drove to the hospital and after a long wait they let her in to see him.  Mom came out and said they only would give one pass and asked if I wanted to use the pass to go in.  Mom was the love of his life and I knew he needed her by his side.  I told her that and she just nodded.  Of course, she knew it too. 

Mom is crafty, and eventually got the doctor to give me a pass.  When I got back there, I insisted that the doctor talk with us about dad’s DNR wishes.  Dad was a bit out of it, but immediately engaged.  “I do not want to be resuscitated under any circumstances.”  The doctor said intubation would help him breathe.  Dad said “I refuse to be intubated.  Instead of intubating me, just shut me down with morphine.  I’ve just about had it.  I’ve had enough.”  This is a man who was wrote on his blog that he was going to shoot the last chemo arrow in his quiver days before – but today a man who had finally concluded he was beyond any reasonable chance for a meaningful recovery.  I leaned in and promised him that we would take good care of mom no matter what happened.  You could just see him relax. 

Dad always knew what he wanted in life, and it was no different in death.  The greatest gift mom and I were able to give dad was making sure his wishes were honored.  It was also the most expensive gift I ever gave, since I loved him so much and he was asking us to let the doctors let him die.  But he was a good man, a good father, and he had long ago earned the right to have me fight to make sure he would be able to exit in the way of his choice.  I gave him my word, and I made sure the doctors and nurses followed his.

We waited for a chest x-ray.  Dad was interactive, even smiled a bit.  Then the results, pneumonia confirmed.  The doctor offered a BiPAP mask, which is a non-invasive mask that covers the mouth and nose and when you breathe, kicks up the pressure to force air in.  Dad was cogent and said he wanted it.   They fitted him with it, and he couldn’t talk easily once it was on.  Just as bad, he couldn’t wear his trifocals over the mask’s seal.  I knew he expected this to be his last day when he refused intubation, but I saw impatience in his eyes when he realized he couldn’t talk or even see properly.

They took him to the ICU, but didn’t let us in for a while.  By the time we got in, dad had asked for Dilaudid painkiller.  He was still cogent, but his plan was in action.  He looked each of us in eye.  He responded when we held him.  The details from then on aren’t critical – he eventually lost consciousness.  Dad would never wake up again, but this is where the real story of dad’s life was told.

His left arm was covered with IVs, tape, and other medical stuff.  His right arm was clear.  My mom was standing next to his left arm, and I was holding onto his right.  It didn’t seem right, and I asked her if she would switch so she could touch his skin more easily.  She paused, then walked to the end of the bed and said “no, he always loved when I rubbed his feet.  I want him to feel me rubbing his feet.”  She knew him so well, and loves him so much.

Eva had asked that I tell him she loved him, so I kissed him and said “Eva wanted me to tell you she loves you, and I love you too.”  Mom said “I love you” and kissed him.

I’d spent so much time at the hospital that I knew how to read a lot of the machines, and I saw dad was about to go.  The nurse said “it’s happening”.  Mom rubbed his feet, held him.  I held his arm and cried softly.  He died the way he lived – with his family at his side, respecting his wishes, and on his own terms.

I looked up and saw mom sitting in a chair at the foot of the bed.  I kissed dad once more on the forehead – his heart had stopped but I hoped he could still feel my love – then  I walked to mom, hugged her, and asked her what she needed.  In a strong, painful voice she said “I need them to take all of that stuff off of him so I can hug him, so I can hold him one last time.”  I told the nurse and he complied in seconds.

Then I saw the most terrifying and beautiful thing I’ve ever seen.  Something that was simultaneously the stuff of nightmares and the stuff of the endings of the most beautiful Disney princess stories.  My dad’s body, his mouth slightly open, still, not breathing, and my mother holding him.  She was holding him lightly in a physical sense, but it was the strongest hug I’ve ever seen.

I know that in intense situations people see things that aren’t real, but what I saw next I will believe to my grave to be real.  Dad’s body looked full.  It will still, he was dead, but even in death it was full.  And with every second mom held him, dad’s body emptied and mom’s grew fuller.  I could see him going into her.  She held him until I saw that migration finish, then, like she knew it was complete, she looked up, let go, and told me that that was the last time she would ever be able to hold him.

Not true, mom.  I’m not a religious man.  I do know that nothing in the universe is ever destroyed; it can change form, but is never gone.  I don’t know how I saw what I saw, I don’t know if it was really visible or just my realizing what it means to spend 50 years madly in love.  But what I do know is that dad is with you, whatever spirit he has, however it manifests, you carry him with you for the rest of your days.

I don’t expect you to suddenly follow the NCAA.  I know it isn’t literally that there are two people in your body, but the story of your lives was so intertwined with your love that at the moment of his death your merger became complete.  At the time I couldn’t figure out why you had such an urgency to give him a full body hug, with all the medical stuff gone, but when I saw what happened, I knew.

You hold in you all of the love you share.  Everybody should be so lucky to draw that much love, enough love to sustain you the rest of your days.

I love you dad.  I’ll honor you by being the best dad and the best man I can be.
* * *

The funeral was recorded on video and was uploaded in three parts.  Many voices spoke about my father, and each deserves to be linked from his blog.  Parts one, two, three.

Sunday, April 22, 2012

Thank you, MCC Google Group

I wrote an email to the Google Group for MCC (, which is a private group for those battling Merkel Cell Cancer and for the people fighting alongside them (if you have MCC or are supporting somebody with MCC, you really need to join that group).  I realized after writing it that my dad would have wanted me to share my thanks and thoughts for this group more broadly.  The email I sent is as follows:

Thank you all for your wishes and your kind praise of dad.

His memorial service is today, and while I'm not going to be distracted with technological issues, I do plan to set up a video camera to capture the event.  Since you've become his family in the same way that soldiers fighting a battle side by side become family,  In a war, there are many battles.  Some warriors are felled in battle.  Some throw themselves into the path of danger to protect others (as with experimental surgeries).  Some mentor other soldiers, preparing them to survive their part in the way (a role my dad took on).  Some get lucky and survive, and some powerful warriors are less lucky.  But in the end, spending years with a band of brothers and sisters fighting a heartless, inhuman beast turns strangers into family.  And so it was for my dad.  He implicitly sought a promise that I'd care for my mother, but the only explicit promise he asked of me on his last day was that I update his blog if he didn't make it.  This family, forged in a shared, frightening common battle against a heartless beast, this family forged in common support and empathy, this family that met not in person but in heart, this family was on his mind on his last day.  As well it should have been.  He died with me at his side, with his wife at his side, with his children and grandchildren in his heart, and with your thoughts and presence surrounding him.  Thank you for that.

I'd like to post the memorial so you can watch it.  I'm not going to be babysitting the video camera, so if there is a technical failure to record the video, so be it.  But if things go as planned, after a few days I'll be able to put up a link to the video.

I see about 3 more posts to the blog.  "Eulogy", "Dying", and "The Future" are likely titles.  I intend to post the eulogy I wrote for him after I deliver it today.  I've been drafting a pretty detailed account of his last day called "dying" (incredibly hard to write, but he found it so important to bluntly share his experiences to help others prepare for what they might face).  I then intend to close with a post about the future, although the ideas about that are kind of amorphous so I'm not sure if that post happens or if it happens the way I'm thinking about it today.

After the last substantive blog post, I'm considering a fundraising and patient support blog post.  This would be links to a PDF version of his blog, a print version, and perhaps a Kindle format version.  They would be available at cost (so PDF free, ebook free, if distributed via Amazon the minimum cost, physical book probably expensive even sold at cost).  Patients need support, and family, friends and patients would be encouraged to use the book without paying.  For those who find value in the book and who are able to afford it, I would include information about how they can pay what they wish, donating to MCC research donate voluntarily in exchange for the book.

I'm off to prepare to bury my father.  I'm having a hard day, but having just read this thread of comments [a set of emails sent by MCC group members in response to my post that he had died], my day is that much easier.

The power of community cannot be overstated, and the power of this community is particularly strong.

Thank you for your love.  I know my dad was grateful for your support to the end, since he went out of his way to expressly say so.  He was fitted with a BiPAP mask much of the day, so he spoke perhaps a thousand words or less on his last day and he reserved some of those for you.  I'm glad he did so.  You deserve it.  

Now I ask each of you to honor him by beating your own MCC.  Please make my father one of the last to die by this disease.  You've described it as a beast and a bully and by all manner of other names, as my dad did, but ultimately it is just some cells in your own bodies making the horrible mistake of thinking that they should keep on reproducing.  It isn't an intelligent enemy or even a powerful enemy.  It is nothing more than a biological mistake.  This isn't to underplay how virulent it is -- it took my dad, a powerful, determined, brilliant man.  But this isn't an intelligent enemy or even a particularly crafty enemy.  It is a mistake of biology, and it will be beaten.  I know it is disheartening to see a warrior like my dad lose his battle, but it would be a tragedy if his death were to do anything but strengthen each of your resolve to beat this thing.

I know that this group has been very civil and avoided language that wasn't family friendly, but in the heat of the moment, waiting to be let in to see my dad, I posted something to facebook that captured my feelings about MCC.  In the law, we make an exception to the hearsay rule for an "excited utterance", under the theory that when somebody is experiencing an enormously emotional, critical moment, they aren't going to lie and they will speak what they're really thinking.  So here is the post, which expressed in no uncertain terms what I was thinking at the moment:  "Just had the surreal experience of following an ambulance carrying my dad to The hospital. spO2 well <80% possible atrial fibrillation, irregular heart rate ranging from what I saw up to 180. Fuck you, cancer." 

As I prepare to bury my father, let me say that "Fuck you, cancer" was, if anything, too kind to cancer.  Cancer, you're taken my dad away from his grandchildren.  You've robbed his MCC group family of his wit, advice and love.  You've made my mom a widow.  You've made me the patriarch of my family at 45.  You've sent a man who could have saved hundreds or thousands of lives practicing medicine for another decade or two to the grave.  You, cancer, must die.  You faced a resolute foe in my dad and beat him, but he wasn't your only enemy.  There are leaders like George and Audi who are organizing forces against you.  You have smart and creative enemies like Paul Ngheim who are preparing to crush you as surely as you've crushed lives and families.  Your days are numbered, and when they write your obituary, I'll be proud of my dad's role as a member of the force that fought against you helped put you in the ground.

I love my dad and I'll miss him.  I know you all feel the same way.  Thank you, on his behalf, not just for the strength you provided him, but for the opportunity to give him to chance to beat MCC if not in himself, at least in the others he helped along the way.

Saturday, April 21, 2012


The following obituary ran in dad's hometown newspaper:


Dave Shuster died on April 18, 2012 after fighting a courageous battle with Merkel Cell Carcinoma.  He was born on Aug. 18, 1940 in Montreal, and moved to Fresno in 1976.  He was a talented diagnostic radiologist well respected within the medical community.

Dave met his wife, Judy, more than 50 years ago.  He was a loving father to his three children, Gary and his wife Dana, Brian, and Michael and his wife Leanna.  He was blessed with 5 grandchildren, Eva, Sara, Sammie, Bel, and Eli.  He is also survived by his mother, Isobel and his siblings, Jon, Robert and Ellie.

In addition to his professional and family accomplishments, he achieved the rank of gold life master in bridge.  He also always had a fun time with his poker buddies.  He never missed an opportunity to play with his grandchildren.

A memorial service honoring his life is scheduled at Temple Beth Israel for Sunday, April 22 at noon.  In lieu of flowers, remembrances may be made to Merkel Cell Carcinoma Research (details at or to Temple Beth Israel at 6622 N. Maroa Ave., Fresno 93704.

The world is a better place for Dave’s being here.  He lives on through his children, grandchildren, and kind deeds. 

Friday, April 20, 2012


Dad died at 10:58 p.m. on April 18, 2012.  He was 46 days away from his 50th wedding anniversary.  In the week prior to his death, he conducted a Seder, watched his granddaughter open birthday gifts, watched Stanley Cup hockey, considered treatment with Votrient, and saw his doctor.  He even saw a concert a couple of weeks ago.

When he first got to the ICU on April 18, he asked me to please update his blog if he died.  I promised I would.  I will expand this post further as I get my thoughts together.  I don't want to post too much until I can do so cogently.

I miss him already.

Wednesday, April 18, 2012

Back in the ICU

Dad is back in the ICU.  His situation is very serious.

CT scan results showed that the left lung is better than the right, but the left bronchial branch is completely closed off (presumably tumor pressing it shut).  The right bronchial branch is fully open, but the right lung is very compromised with pneumonia.  There is some pleural effusion.  

One of the nurses and one of the doctors, on different occasions, said that the outlook was very bad.

Other than the Dilaudid causing him to be a bit loopy, he is very cogent when his O2 saturation is good.  When it isn't good, he is very out of it, eyes rolling back, etc.  His O2 saturation ranges from 70% to 100%.  He is on a BPAP mask as he refused intubation.  He has also given a very broad do not resuscitate order.  In relation to the intubation refusal, he said, paraphrasing, "instead of intubating me, just shut me down with morphine.  I've just about had it.  I've had enough."

His breathing is very labored.  It reminds me a lot of when my daughter Eva was a newborn and developed RSV.  You can see his stomach trying to suck in to help draw air into the lungs.

He seems to be cogent, at peace, and just wants to stop hurting.

I love him.  I hope tonight goes the way he wants it to.

Following an ambulance

It is a surreal experience to follow an ambulance with your father in it.

I got a call around 9 am from my mom saying that my dad is in severe respiratory distress and he doesn't think he can make it to the hospital in a car.  My mom said she was probably going to call an ambulance.  I told her I agreed, call the ambulance.  I arrived there just as the paramedics (full fire truck + ambulance -- I paid my taxes yesterday, and all of my annoyance at writing that check is gone with this demonstration of what those taxes pay for) were getting there.

My mom and I filled the paramedics in.

My dad is currently in the ER being seen.  There is a one-visitor-at-a-time policy, and I'm sure my dad would be more comfortable with his wife at his side, so I'm patiently waiting in the waiting room.  The doctors are confirmed atrial fibrillation.  They also hear a wheezing noise they don't like and they're taking him in for a chest x-ray.  I assume the cancer impinging on the bronchi is making them worry about pneumonia, but I'm not even close to being a doctor so that is just guessing.

I'm post more when there is more.  At this point, it is all scary, sad, and a great unknown.

Monday, April 16, 2012

About the Author -- Curriculum Vitae

                                                         CURRICULUM VITAE

                                                      DAVID N. SHUSTER, M.D.


            Date of Birth:              August 18, 1940

            Place of Birth:             Montreal, Canada

            Marital Status:             Married (Judy)

            Address:                      [redacted]
                                                Fresno, CA 93720

            Telephone:                   Business:        [redacted]
                                                Home:           [redacted]


            COLLEGE:                            McGill University
                                                            B.S., 1961

            MEDICAL SCHOOL:           McGill University
                                                            M.D.C.M., 1966

            INTERNSHIP:                       Jewish General Hospital-Montreal
                                                            June 1966 - June 1967

            RESIDENCY:                                    Jewish Hospital-Brooklyn, N.Y.
                                                            Obstetrics and Gynecology
                                                            June 1967 - December 1967

                                                            Brookdale Hospital-Brooklyn, N.Y.
                                                            January 1968 - June 1968

                                                            McGill University-Jewish General Hospital
                                                            July 1968 - June 1971

PRACTICE:                         Diagnostic Radiology
                                                St. Mary's Hospital, Montreal
                                                June 1971 - August 1976
                                                Saint Agnes Hospital, Fresno, California
                                                September 1976 - April 1993

                                                Fresno Imaging Center Medical Group
                                                May 1993 – December 2004

                                                Sierra Imaging Associates Medical Group
                                                January 2005 to present

                                                [Note that this version of the CV predated his work at Kaiser]


            L.M.C.C.                                                               1968
            National Board of Medical Examiners                       1967
            Certified Specialists of Province of Quebec               1971
            Fellow of Royal College (by examination)                 1971   
            Royal College certification (Radiology)                     1971
            Diploma of American Board of Radiology                1972
            California Certificate Number                                  [redacted]


            Fresno-Madera Medical Society
            California Medical Association
            Central Valley Radiological Society
            California Radiological Society
            Radiological Society of North America
            American College of Radiology

                                                                        1980 - 2000

LECTURER IN RADIOLOGY:                McGill University
                                                                        1973 - 1976

PUBLICATIONS:                Shuster, D., Palayew, M.J., "Accordian-Like Compression of a Calcified Splenic Artery: A Plain Film Roentgenographic Sign of Splenic Enlargement". AJR 116:423-425, 1972.