When they gave me this pen

I'm on vacation at home right now. I'm not a big jetsetter/traveler type, I'm more of a relax and reflect type with my vacations, I like to use spare time to get my mind and my environment in order. Standing in 2 hours worth of line to make a flight on time, getting ripped off on cabs and having to recover quickly from jet lag isn't exactly my idea of relaxation, but for many I can see the appeal because I'm sure it's quite exciting.

In November, I'll be on house medicine again, and will have to decide whether to take off the weekend of my friend's wedding or the weekend of my parents' visiting. Perfect.

While I was on night float, a patient came in with his family. He was an older gentleman, very nice man (a rarity to find kindness and gratitude in the North American patient in this day and age) and he was dying of metastatic prostate cancer. In the last month, he had lost 15-20 pounds, had become more depressed, and had a resurgence of back pain. He had not been taking his pain medication as prescribed because he was "not big on taking medication" apparently. He was somewhat anemic, for which our hem-onc department was going to likely transfuse him in the morning, we were just there to control his pain overnight. As soon as we gave him his regularly scheduled medication his pain was adequately-enough controlled for him to sleep, but that wasn't the reason for which I mentioned him here. My interaction with this patient marked my first advanced directives discussion in my medical career. I went over everything on the hospital advanced directives checklist with him; Intubation, mechanical ventilation, these drugs, those drugs, chest compressions, defibrillations, pacing, placement of lines, surgical intervention, everything. The only things he didn't want were intubation and ventilation.

When I got into residency, I was gifted a black Cross ballpoint pen. It's nice and heavy, and it writes well. It's probably only worth about $45, but for a pen and for me, that's a lot. I always imagined myself signing various different things with this pen; prescriptions for patients when the EMR was down, car and house documents, medical office papers, medical license paperwork to be submitted to some regulatory body, personal cheques for important things or extravagances (which, in my life so far, have been few), etc etc etc. I never once thought, when they gave me this pen, that I'd be lending it to a dying man to sign his end-of-life in-hospital emergency decision checklist. It was a tough conversation. It also had to be done, and as far as I was taught, it is always best done by a physician.