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I have been in Family Practice for 30 years now, out of which 23 in the same office that used to be my grandmother's home. In spite of the rule that a doctor should not treat his family members, I do it all the time. Even before I graduated from residency, I wrote prescriptions for narcotics to help my mother who died of Multiple Myeloma at the age of 69. So when I opened my practice, in the same neighborhood where I grew up, it was only natural that other members of my family would become my patients. My father, my four children, my wife and her parents, my brother and two of my aunts, were all my patients, not to mention many friends, old and new, who live in the area.

My rationale for doing so was that I felt I was able to separate between my emotions and my professional knowledge, and I made sure I treated my relatives the exact way I would treat any other patient. And even if my family was under the care of another doctor, I would anyhow be involved in the treatment they received.

After my mother's death 28 years ago, my 71-year-old father continued to live the active life of a healthy man. He had been retired for 6 years from his job as a general manager of a large rubber factory. He kept a strict daily routine, maintained his home, went for walks at the beach or in mountain trails, and drove his car every day to one of his favorite restaurants for lunch.

Driving his car was for him the symbol of his masculinity and independence. He owned many cars in his lifetime, starting from a 2nd hand convertible Austin 7 with a manual starter, which he loved almost as much as his children, and did all the repair work on by himself. He remembered periods in his life by the car he owned at that time.

He rarely consulted me for medical problems, doing his best to avoid putting extra burden on me, since he always thought that I was under too much stress due to my work and family obligations. Luckily for both of us, he did not suffer from any major illness. Mild hypertension, benign prostate hypertrophy and biliary stones were his main medical problems. A suspicious skin lesion that I discovered on his flank turned out to be malignant melanoma, which was removed without further consequences.

When my father was 80, his urologist requested a PSA test. The result was 15—which is quite high, even for his age. A rectal exam performed by the urologist revealed a hardened area in the remaining prostate, which was most likely due to cancer. I decided to discuss the options with my father in the most open and direct way—since I knew how important it was for him to make his own independent decisions about his life. We discussed the need for a transrectal biopsy in order to make a definite diagnosis, followed by possible hormonal therapy, chemotherapy or radical surgery. We also discussed the option of not doing anything, not even a biopsy. My father chose the last option—he felt well, and did not want any medical test or treatment to render his freedom and independence.

I felt strongly that I acted in his best interest. He made it clear to me, in many occasions, that he would not desire any life prolonging procedures if he suffered from an untreatable disease. I knew [End Page 9] that prostate cancer at his age could be very slow growing, and that most patients die of other illnesses before the cancer spreads in their body. We checked his PSA level several times after that, but when my father noticed that it kept rising, he suggested that we stop measuring it, so we "don't get upset about it". I agreed.

The years went by. At my father's 85th birthday we organized a big celebration at the nursing home where his elder sister lived. He looked handsome and sharp minded as ever. He continued to drive his car, even though he limited his journeys to short distances and mainly during daytime. Every two years when it was time to renew his driver's license, he asked me to sign the medical form. I did so without hesitations, since he had no disease that would hinder him from driving a car. But then when he was over 90, he had a series of small accidents. Always not his fault, he explained. He saw no reason that he should stop driving, and I was afraid that taking away his driver's license would be a fatal blow to his feeling of self–esteem and independence.

As he approached his 94th birthday, he started to complain of severe pain in his entire body—hands, legs, back. Not his usual backache, which he knew how to handle, a much stronger and persistent pain that disabled him from performing his daily activities, and woke him up at night. I feared the worst, and a bone scan reaffirmed my suspicions—he had wide metastatic spread throughout his entire skeleton. A PSA test came back close to 1000. My father responded well to hormonal therapy, with minimal side effects, and with marked improvement of his bone pain. Since I was the one who always accompanied him to medical appointments and treatments, we now had our monthly routine of going for blood tests, IV zolendronic acid to treat his osteoporosis and prevent bone fractures, and other medical appointments. He always walked in the medical office in a brisk and steady walk, his tall stature and handsome appearance making a unique impression on the staff. He never forgot to introduce me, if there was a new member of the staff, as "Dr. Ritter, my son and family doctor". And after the treatment or test was over, we would go for coffee or lunch at a nearby restaurant, and I knew there was no use of offering to pay the bill—my father would always insist on paying it, making it a small treat for me, his son and doctor, the only person he could trust and rely on.

Two more years went by, and the bone pain reappeared. A more advanced hormonal therapy has produced limited response. After several months we decided to stop all treatments, since their side effects were worse than the symptoms of the disease. I treated my father with strong painkillers, making it possible for him to function without impairing his alertness and consciousness. But his memory began to fade away slowly, along with his hearing. He agreed to try wearing a hearing aid, which took a long time to adjust, and again I was the one responsible for accompanying him. My brother and sister did their best to help out, but I was the one who made the decisions and was responsible for carrying out all that needed to be done. Close to his 96th birthday he had another "small" car accident. This time I insisted that he stop driving. He agreed, but decided to keep his car since it had a "handicapped" sticker on it, so we could drive him and use the parking slots designated for handicapped persons. The three of us took turns driving him for lunch almost every day, thus having some more quality time with our father. But his condition deteriorated, he fell several times, luckily without breaking any bones. It took us several months to persuade him to have a live–in aid in his home. We found Chris, a pleasant and devoted care taker. But my father's cognitive state deteriorated and he became paranoid towards Chris. He accused him of stealing and cheating. We had to juggle between supporting Chris, and not blaming our father of being cognitively impaired.

Chris took my father out every day for a walk in the park. One evening, my father took his car keys with him. When they passed by his car, he suddenly dropped his hold of Chris' arm and opened the door on the driver's side. He sat in the driver's seat, started the car and shouted at Chris that he should enter from the passenger's side and join him for a ride. Chris hesitated. He was frightened [End Page 10] to ride in the car with my father driving it, but felt that it was his duty to remain with my father and take care of him, whatever happened. Chris called me, alarmed and frightened, not knowing what he should do. I was shocked, too, worried, and angry. My father behaves like a child, and I have to be the responsible adult? What a sudden reversal of rolls! After a few seconds of hesitation, I told Chris to do what he felt was right, and that he did not have to join my father if he was too frightened to do so. I called my brother and we both rushed to our cars, staying in contact with Chris who decided to join my father. He was heading towards the beach, his favorite place. My brother, Dan and I took different roads to the beach, which looked like a scene from an action movie of police cars chasing a criminal. Finally my dad and Chris reached the beach and parked there. Dan and I appeared at my father's great dismay. He was angry at Chris for giving him up and told him to step away from us.

We sat at the restaurant, and tried to convince my father that what we and Chris did was for his own good, and that he should not drive any more. We continued the discussion after we returned to his home, and finally managed to convince him that it would be best for him if we took the car from his driveway, so he would not have the temptation to drive again. And so we did. I took the car and felt relieved. I was responsible, as both his son and his doctor, for the possible consequences of his behavior. I did not want to take any more risks, even at the cost of upsetting my father. I also decided to inform the ministry of transportation that he is unable to drive now, and that they should take away his driver's license.

The next morning I got a call from Chris. "Your father is furious! He keeps standing at the window and looking for his car, thinking it was stolen". I asked to speak to him.

"You stole my car. Bring it back right away or else I will call the police!" He exclaimed.

I tried to explain, but he would not listen. He promised not to try to drive it anymore—he only wanted to have it near him so he could watch it from his window.

I was overwhelmed. I never heard my father so angry and desperate, and he never talked to me this way. Finally I agreed to return the car, hoping that Chris would now be more alert and make sure my father did not repeat this trick.

I felt this was a turning point in our relationship. My father, who always trusted me blindfolded, became paranoid towards me. I wondered if I should continue to be his doctor, since his trust in me had faded. It was hard for me to overcome my feelings of anger and insult.

I knew it was too late to transfer him to another doctor. This would mean deserting him, or punishing him for what he did, when the cancer, which probably had spread to his brain by then, was responsible for his bizarre and uncontrolled behavior.

I continued to be his doctor, and he continued to respect my decisions. But from that day on his condition deteriorated rapidly, he began to lose his strength and his willpower. We continued to take him out for lunch, but he could hardly walk, and began to lose his appetite. I respected his wish to avoid any life–sustaining treatments, and kept him at home, where he felt safe and comfortable. Close to his death I asked for the home hospice team to join me in caring for him. In his last days, the three of us took turns in staying near him, watching his gradual decline, diving into worlds of loss of consciousness and briefly returning to the world, and finally losing contact with reality, until his last breath, witnessed by Yael, my sister, the eldest of the siblings. He was four days short of his 97th birthday.

18 months have passed since my father's death, a period in which I found myself wondering a lot about my role in the life of my father—as a son and as a doctor—wondering about the emotional burden on me and my family. My father appeared in my dreams, in different forms, always as a strong and demanding person.

I feel strongly that my father received the best care he could wish for. I escorted him in his journey from wellness through sickness and until his last day on earth. I made sure he received the best care, according to his wishes. But was it also the right [End Page 11] thing for me? Is the price I paid worth the benefit? It is so hard to know, but I feel that I could not have done it differently. I continue to take care of most of my family members and some of my friends, but try to be more aware of the burden that this practice puts in me.

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