reflection104 year-old Buddhist Monk was brought into the hospital by his students due to fever and chills, without any known past medical history and did not take any medications. Patient was fully ambulating without history of dysphagia with some basic assistance with ADLs. He was active in daily teachings for 15-20 students.

Chest X-Ray demonstrated extensive Right Lower Lobe Infiltrates. After medical treatment for several days, his Pneumonia was not improving in the short term and his students wished to take him home. They were agreeable to antibiotics. The Pneumonia took a toll and thus on several repeated clinical swallow evaluations there was obvious and clear s/s of severe dysphagia. Other etiologies were considered due to profound dysphagia but further work-up was declined. There were several rounds of discussions about nutrition options given the wishes to “keep him going as long as possible.” Ultimately a PEG was decided. This was decided following several conversations between his students (also DPOA), SLP, MD and Case Management. We asked and answered questions about meaningful quality of life without food or liquid. Ultimately we learned that meaningful quality of life for this patient had nothing to do with nutrition but the ability to continue to teach.

In fact, it was never asked, “Will he eat again? Can he have sips of water? Can he have some ice cream for comfort?”

But it was asked, “Can he still teach us?”

Because he was so weak and not making much attempt to speak, it was important to ask “In what ways does he teach you, now?”

They replied, “He teaches mostly by example; sometimes he does not have to speak at all.”

At that point it was decided, “You should go with a PEG, because we believe he can still teach you.”

I’ll never forget seeing him wheeled away in an ambulance gurney two days later, after the PEG placement, with 15 of his students following closely behind. They all had looks of joy, as the monk was going home to thrive. The teacher’s quality of life was dependent on his student’s quality of life. I learned a lot in the several days he was in the hospital. My focus, at first ,of course, was swallowing ability and what research tells us about quality of life with PO. However, just as the students learned from their teacher by example, I was taught that PO did not equal quality of life for this man, but rather his existence alone was quality enough.

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