Chapter Text
“Can I be of any use to you today?” Castiel poked his head into the discharge planning office and gave a soft smile along with his usual question. He’d found early on that people expected a certain demeanor from him and tried hard not to live up to the stereotype. He wasn’t a funeral director after all; the patients he took care of were unequivocally alive. He’d always hated hearing people say that that someone was “dying”. People weren’t “living” or “dying”, they were alive or dead; and if they were alive they deserved to be treated that way. In consequence, he kept his manner light, forthright and free of unnecessary euphemisms or vagaries. He had watched far too many well-meaning practitioners babble and deflect, thinking they were telling the patient that their disease was running its course, only to find they had instead given more false hope. Hope was always present, of course, it was a gift from God. The only thing that changed was the goal of that hope. Hope for a miracle cure was replaced with hope for a pain-free night, a day to spend with the grandkids, appetite enough to eat a favorite meal.
Castiel liked providing that kind of hope.
He hated the other kind, and that had caused some doctors and nurses to hate him, but that was all right. He bore their dislike patiently, and tried to educate them. He wasn’t, as some had jokingly called him, The Angel of Death; he was more like The Angel of Universal Experience, The Angel of The Elephant In The Room. It was simple- everyone had an expiration date, and it was (except in cases of sudden catastrophe) easy to see when it was coming.
At least it was easy for Castiel; it was a major source of irritation (to him and to those around him) that others couldn’t see what he saw. His supervisors often berated him for wasting their time discussing solutions for things that “weren’t even a problem yet!” but he liked having a Plan B. This was because he hated having to waste the precious and limited time his patients had left scrambling to adapt to a change that any nurse with half a brain would have anticipated.
The families of his patients often said “How do you always know what’s coming next?” and the answer was simple- the signs were there, all he had to do was interpret them correctly. His patients loved him, but his colleagues often cringed when they saw him bearing down on them, with an expression which told them they were about to engage in an argument they were almost certainly going to lose.
He hadn’t always been in this field- in fact, he’d had NO intention of ever working in hospice. It held no interest for him, but he’d discovered that you didn’t choose it, it chose you. He’d found a satisfying career as a home health nurse, and it suited him fine. He got to work with one person at a time, in their own space, learning what help they would accept, and where their boundaries were. He taught them how to best take care of themselves within the limits of their resources. In a hospital setting, he couldn’t give his undivided attention, and all too often, everyone needed everything all at once.
It was a directive no clinician could fill.
And, as he sometimes admitted to colleagues after a few drinks, one of the perks of visiting patients in their own homes was that when the patients had had enough of him, HE could leave.
He’d been very happy in his work, until he was approached by his supervisor for a favor. One of the hospice team was going out on medical leave for 3 months. Could Castiel cover her cases? He was assured that his position in home health would be held for him, and that he would receive a pay boost for the duration of his time in hospice. He’d done the three months, and, when it was over, had asked to stay.
It had been hard at first. He felt like a fraud, pretending he could understand what these people and their families were going through. He’d tried to be serious, sober, and professional, and wound up scaring the patients half to death. In desperation, he’d gone to his mentor and asked “What are the magic words?”
“What magic words?”
“The magic words that make everything all better.”
There weren’t any of course; but he had discovered that there were still some that helped. Words like “Hey, there, how’s it going?” or “You look like crap; what happened?” gave people something that nothing else would- normalcy.
Death wasn’t a topic people enjoyed talking about, of course, but when it was coming, nothing made people feel better than being seen, here and now. It was a mistake to treat people with kid gloves; most of them hated it. Castiel had struggled with these interactions, wondering how to treat people with terminal illness, and had come to the conclusion that it was best to treat them just like anyone else. Sometimes that meant joking with them, and sometimes it meant holding them when they cried. You looked at what was wrong, and you tried to make it better.
Sometimes, this was easier than others.
The patients under his care at the hospital got very strict instructions- if they were anxious, or in pain or having any other distress, they were to ask for their medication. If they were told “it’s not ordered for another hour” they were to ask the nurse to call the doctor and get the order changed so they got their symptoms under control.
This irritated many of the staff, who would angrily ask if he WANTED the patient to become addicted to pain medication, as if a person whose bones were exploding from the inside as cancer cells ballooned out were somehow manipulating the system to get illicit drugs. He calmly lectured them on the concept of opioid tolerance, and pointed out addiction was hardly a valid worry in a person within arms’ reach of death. A few people thought him a danger, most found him a relief, his sanction enough to allow them to give the patients what they needed without feeling an irrational sense of guilt.
It was frustrating to fight old prejudices, but Castiel had been doing it for a long, long time.
He’d been 16 when he finally admitted to himself that he was really, truly, gay. He’d developed a desperate crush on a new student, a mail-order, central-casting-send-me-a-bad-boy, jaw-dropping chunk of physical perfection by the name of Dean Winchester. Dean had rolled into town in a classic muscle car, wearing a leather jacket and a pagan amulet. He’d landed in the preppy, penny-loafer suburban high school like Apollo descending to earth, and Castiel’s world had changed forever.
Dean hadn’t noticed him, of course. Dean was cool, and kids who’d previously thought they were had flocked to his orbit. They’d quickly realized, however, that while Dean’s image had a gravitational pull, the boy himself pushed people away like the negative poles of a magnet. You could hang around, but if you drifted into his personal space, you bounced right off. Girls could get close, at least physically. They could touch his body, but not his soul. He didn’t talk about himself the way most cool kids did; never bragged about his car, or his conquests, just showed up, sat in the back row, put his feet up, and stared at the world with an expression of calculated insolence.
He also carried a knife in his boot.
No one else knew this, and that was how Castiel knew Dean was different. Anyone professing to be cool would have made sure everyone (except the teachers) knew he came to school armed. The only reason Castiel knew was because they had gym class together. That had been enough to send him into paroxysms of dread, unsure if he would pop a boner or burst into flames of sheer euphoria if he ever laid hands on the guy. He’d found himself changing clothes next to Dean before class one day. He had been trying (and failing) to keep his eyes to himself when he glanced over and saw him deftly unstrap a small blade from his ankle, dropping it into his boot before pulling on his gym shorts. Dean, whose green eyes missed nothing, didn’t miss this, and he growled “Tell anyone, and I’ll rip your lungs out.”
“I…I…I won’t.” Castiel squeaked, then blushed a horrible shade of maroon.
Dean looked up and snorted. “Jesus, Cas, you look like you’re about to have a stroke. No point in dying before I kill you.”
Castiel tried to swallow, but choked instead. Dean knew his NAME?
Dean looked startled and apologetic “Seriously, man, are you ok? Do I need to get the teacher?” Castiel shook his head mutely, and Dean laughed. “Jumpy, aren’t you?”
“It’s not every day someone threatens to kill me.”
Dean rubbed the back of his neck, and gave a self-deprecating chuckle. “Sorry.”
“If I’m still alive at the end of the day, I’ll gladly accept your apology.”
For the first time, Dean actually looked at Castiel. His eyes were green, and held a sparkle of flirtation. “Then I’ll have to make sure nothing bad happens to you until then. What are we playing today, anyway?”
“Soccer” Castiel replied with a shudder.
Dean clapped him on the shoulder. “Just run up and down the sidelines, and pray no one passes you the ball.”
“Does that work?”
“It has so far.”
Castiel was NOT a jock, at least by high school standards. He loved distance running- the solitude, the endorphins, the opportunity to do nothing but breathe, sweat, and get lost in thought, but no one here seemed to think that counted as athletic. On the plus side, however, it meant he could run effortlessly for the duration of the class. To his surprise, so could Dean.
“Do you run?”
Dean got a strange look on his face. “Nah, my dad’s ex-military, so he likes us to keep in shape. This is nothing- at least it’s not snowing. Last year I had to do five miles in a blizzard- nearly froze my ass off, and almost got taken out by a snowplow.”
Castiel wondered what kind of father forced his child to run in such dangerous conditions, but something in Dean’s face kept him from asking personal questions. Instead he said “There’s an indoor track at the Y, and they let high school kids run for free after school. If you want, I could show you where it is.”
For a split second, Dean looked…hopeful? Then a mask dropped. “Thanks, but I got stuff to do after school.” Without another word, he turned, and headed out of the locker room, leaving Castiel wondering what he’d done wrong.
After that, Dean avoided him, and Castiel felt ashamed. Had Dean somehow sensed what Castiel was? He’d tried to keep it a secret, and he knew he didn’t ACT gay. He didn’t have a high pitched voice, didn’t have campy mannerisms, didn’t limply flop his wrist or do any of the other stereotypical things that mass media and the general population referenced to define men who loved other men. He LIKED feeling masculine; having chest hair, the way his facial stubble came out to play around 5 pm. He favored typical male clothing, typical male colors, typical male EVERYTHING, except for sex. His wet dreams centered around hard bodies and even harder dicks.
His parents constantly said things like “once you find a girlfriend” or “when you’re married and have kids” but truthfully, he was pretty sure those things were never going to happen, and he was terrified that his parents knew it too. So he tried. He took platonic friends to the prom, and politely staved off the advances of girls who thought he was good-looking enough to compensate for the social stigma that came with dating Cas the Ass. At church, he prayed to God to make him straight, but his prayers went unanswered.
“I’ve got a couple of potentials for you; can you stick around until after the morning meeting?” Laurie, the discharge planner asked, glancing up from her computer.
“Absolutely.” Castiel’s job was to come to the hospital every day and talk to any patients who might need to discuss options . He had to tread a fine line- most doctors had no problem documenting a terminal prognosis in a chart, but few had the ability to deliver it in person. It wasn’t really their fault; doctors weren’t trained to deliver bad news.
No one was.
Over time, he had developed a rapport with the staff, and knew how each one approached the conversation. His personal favorite was Dr. Singh, who would say “Ah, here’s Castiel. He’s going to talk to you about hospice- I think that’s a good idea, so I’ll let him get on with it” then bolt from the room. Others would talk endlessly in circles, before saying “I’m sure you understand what I’m saying, so I’ll just let you iron out the details with Castiel.” Then he would have to explain, slowly and clearly, what their future held.
Every morning the discharge planners and the doctors met to decide who could go home, and who had to stay in the hospital another day. Insurance companies, of course, thought everyone should go home, and were making it harder and harder to do anything but the most basic interventions to stabilize patients before sending them out the door. For those whose diseases were irrevocably worsening, it was often a revolving door. Hospitals these days didn’t get paid to cure disease; the most common diseases HAD no cure. For most people death would come in the form of chronic heart or lung disease, complications from diabetes, or dementia, their bodies slowly turning themselves off until all vital functions ceased. For those diseases, there were no reversals, only management strategies. None of those strategies worked forever, and people who had lived for decades with a disease that limited their activity were often shocked to find out it was now going to take their lives.
Cancer was a bit different. Many people got cancer, sometimes more than once, sometimes multiple different kinds of cancer. It wasn’t universally fatal, in fact most kinds were curable. There were new treatments being developed every day, and that was both a blessing and a curse. It was a blessing for those whose disease responded favorably to the treatment, but a curse for those who didn’t, who kept being bounced from clinic to clinic in an ever-more elusive search for a cure, like a victim of domestic abuse, wooed back into the relationship with the promise that THIS time, things would be different.
Doctors classified cancer in two ways-“curable” and “treatable,” but few of them explained the difference to the patient. “Treatable” was the opposite of “curable” but the patients didn’t know that, and accepted the good news at face value. People rejoiced to hear that their cancer was treatable, unaware they’d just been given a terminal diagnosis, and that treatment was often little more than a bandaid. Most doctors didn’t have the heart to tell them otherwise.
An hour later, Laurie snagged him in the hall. “We’d like a consultation for the patient in room 22. He’s a 66 year old man with stage 4 pancreatic cancer that’s spread to lungs, liver, and bone.”
“Damn.”
“Pretty much. He was admitted with dehydration, sepsis, and uncontrolled pain. We’ve rehydrated him, and knocked out the infection for now, but the pain’s still a pretty big issue, and he wants to go home. He refuses all pain meds, so it’s gonna be a battle. According to the staff nurses, he’s a pain in the ass-verbally abusive, throws things, screams at his kids on the phone every time they call.”
“Have they ruled out brain mets?” People whose cancer traveled to their brain often had personality changes, which was heartbreaking to those who loved them.
“Yeah, brain CT was negative- some of it might be the pain, but most of it’s just HIM.”
“Is he still getting chemotherapy?”
Laurie sighed. “There’s a new oncologist down at the clinic, and she’ll give chemo to a corpse. This guy’s been on every possible drug, including clinical trials. The tumors have grown, the disease has spread, he’s lost over 80 pounds and every time he gets even low dose chemo, he gets a life threatening infection because he’s got no immune system left.”
“In other words, the treatment is killing him faster than the disease.”
“Exactly.”
“Has anyone explained that to him?”
Her silence spoke volumes.
“Ok, I’ll see him, but I’ll need to talk to oncology first, make sure they’re on board with this. If I can get everyone on the same page, I'll admit him to service here, try to manage the pain, then get him home. Insurance?”
“Medicare- he’s a veteran but the cancer must not be service-related or he’d be going to the VA.”
Ok, then having him go on inpatient hospice buys you some time without having insurance deny his stay, and it gives him a better chance of success once he’s discharged. Who’s the doc?”
Laurie gave him a sympathetic look. “Raphael.”
Damn again.
Dr. Raphael was, in Castiel’s opinion, everything that was wrong with the medical profession. Absolute, intolerant, and unbearably arrogant, he deeply resented collaborative input from anyone, especially a nurse, one who didn’t work for the health system, whose job couldn’t be threatened. One who didn’t have to kiss his ass, in short. The two of them existed in an uneasy detente, where Raphael resentfully followed Castiel’s recommendations, but made it clear he was doing it only because he was being forced. Gritting his teeth, Castiel picked up the phone and paged him.
“Raphael.” The man’s voice came over the line, clipped and impatient.
Hello, Doctor, it’s Castiel from North Star- I’d like to offer your patient in room 22 the option of inpatient hospice. Maybe we could start him on some IV steroids, then transition him to pills, and see if we can get him home?” Castiel hated having to sound like a supplicant, but in this case, there was no choice. Raphael responded best to humble, tentative “suggestions”. He would scoff, mock Castiel’s ideas, then grudgingly follow them, since they were firmly rooted in best practice and hard-won clinical competence.
“He doesn’t need you- he wants to continue treatment.”
“Does he understand that the last treatment nearly killed him?” This was a simple truth- the drugs Mr. Winchester was being given unfortunately couldn’t tell the difference between a cancer cell and a blood cell. The result was anemia, and a depleted immune system that made the patient susceptible to constant infection while robbing him of the ability to fight back. “I’ll be discussing his case with the oncology team as well, and won’t move forward unless they think it’s the best path.” Castiel threw Raphael another bone. “I’ve talked to the pharmacist, and Jennifer recommended dexamethasone. She’ll discuss it with you if the patient decides to sign on.”
Dr. Jennifer Webber was the hospital pharmacist, a brilliant woman who was always ready for the challenge of collaboration on difficult cases. She’d told Castiel once that he consulted with her far more than any of her actual hospital coworkers.
“It’s nice to have someone ask for pharmaceutical solutions, instead of just going for the quick fix, especially when the quick fix doesn’t last” she said, after one particularly difficult case. The patient, a young woman with a complete bowel blockage due to intestinal tumors, was having uncontrolled vomiting and nausea, and was dependent on a nasogastric tube to drain her digestive system of fluids. Jennifer had recommended a drug which dried up the secretions, allowing the woman to be more comfortable, no longer tethered to a suction machine via a huge tube up her nose.
“Fine, but only if oncology agrees.” Raphael’s voice was curt, and he hung up without further comment.
Fortunately, Castiel’s own medical director was a much easier sell.
“Hey, Bal, I’ve got a hospital admit- fifty nine year old male, advanced pancreatic cancer that’s spread pretty much everywhere- liver, lungs, and bones. Poorly controlled pain, so I’d like to manage him with IV dexamethasone, then get him home on oral steroids. He lives alone, but if we can get the pain under control, that should improve his functional status, and I believe there’s family in the picture, so hopefully social work can help them set up care.”
“Ever consider leaving some work for the rest of us to do?” Dr. Balthazar Dawson was a good friend, as well as a superlative colleague, and Castiel took the needling as it was intended.
“Just trying to think ahead.”
Balthazar laughed. “Sounds like a good plan. Do you need me to make a visit, or do we have what we need?”
“I haven’t met with the patient yet, wanted to get all my ducks in a row first before I started making promises I couldn’t keep.”
“Remember, my friend, it’s a team effort for a reason- you don’t have to do it all yourself.”
Castiel knew he was talking about more than just the case, but he didn’t want to talk about it now.
“You’ve got it- I’ll let you know how it goes.”
The next piece of the puzzle was the oncology team. Castiel made his way down to the first floor, and through the hospital complex to the wing that housed the cancer clinic.
“Is Chris in?”
The receptionist smiled. She never used to- until her mother came under Castiel’s care a few years ago. Now, if anyone from North Star Hospice needed something, she made it a priority. “I’ll check- if she’s tied up, do you want to wait?”
Castiel nodded, but the nurse practitioner was just getting off the phone, and waved him in with a smile.
“What’s up?”
“John Winchester is up in room 22, and discharge planning thought I should talk to him.”
Chris nodded. “We sent him up there when he showed up for his latest treatment with a fever of 102 and another 10 pound weight loss.”
“What’s his prognosis?”
“The last CT scan showed tumor growth, and new mets, but he’s hell bent on continuing treatment.”
“Has anyone told him it’s not working?”
She gave him a look over her glasses. “You know Dr. Langley, she just asks what the patient’s goal is. Every time he says his goal is to get better, she continues the treatment.”
Castiel had encountered this before- doctors who thought they had obtained informed consent when they’d left out all of the information needed to GIVE that consent. As a result, terminally ill people eagerly embraced a treatment that would do little to prolong their lives, and nothing to improve the quality of it.
“Let me talk to him, and I’ll let you know how it goes. If he agrees to come on service, will Dr. Langley follow him once he’s home?”
“No problem- and if you can get him to agree to hospice, we’ll all chip in and send you a fruit basket. This guy’s a tough one.”
Now that he’d gotten approval from all of the doctors involved in the patient’s care, he was able to approach the patient himself.