One of the very first patients I had admitted was a 50-some year old father of three with a newly diagnosed colon cancer. His case read just like my father’s. Sudden changes in stool caliber. More bloating and fatigue. His wife started noticing that he looked thinner.
By the time I had approached him in the hustle and bustle of the emergency department, the news had already been broken by the emergency physician. “You have colon cancer,” he remarked on the bluntness of that interaction. It had left him in such shock that he had little to say for most of the day. I took my time to be thorough, answering questions, gathering the history, doing the physical - his moderately ascitic belly and an enlarged liver already hinted at something more sinister. Having already been subjected to one rectal exam, he asked if I needed to double check again. I politely declined to which he breathed a great relief.
I excused myself to review his CT scan, to get a better understanding of what was driving everything. There, on the black and white screen I saw a liver so large it seemed there would be no space for anything else in that belly. Pocked full of cysts and irregular tissue, it screamed only one conclusion: gross metastasis.
"A few more tests," I reassured him and then he would go home, to follow up with the oncologist for further management options. I explained that the cancer had spread and that the options will be limited. He digested the news silently, his eyes flickered across the floor as he concentrated. When his wife arrived, I made sure to break the news gently. She wept regardless.
By the time I had sent him home, his belly was flatter once again, having been drained of all of the malignant fluid. The oncologist was to follow up with him within a week’s time. The prognosis was guarded but we agreed that he will be fine for at least the week.
Or so we thought.
It was a surprise to me then that not one week later, I saw him again on call in the emergency department, this time looking worse. He was confused, agitated, and grim - his skin had turned yellow. I quickly texted my attending: “Encephalopathy. Icterus.” The response was immediate: “Shit.”
Because most of the patient’s liver had been replaced by metastatic tissue, his body could no longer bear the burden. The liver had started to fail and with that, his kidneys were beginning to shut down. He was quickly transferred to the ward.
We rediscussed code status with the family with the end drawing near and it was decided to change his care to palliative. We kept him comfortable until he died a few days later.
Precipitous multi-organ failure is uncommon to see in someone who is still very high functioning. We never would have expected him to decline so rapidly. It was a surprise to everyone that he could be here one week and gone the next. Given his disease, there would not have been much more we could do medically.
But there are always things we could have improved on. From delivering the diagnosis with care, to advocating for a private room in his final days, to addressing the psychosocial needs of the family. These are areas that we can strive to do better. At the end of the day, this patient was not his colon cancer, he was a person. With a wife and three children. A friend to many.
These were the pieces, in the torrent of changes that ensued on his second admission, that were lost.
"The patient died surrounded by his loved ones. We are grateful to have been involved in his care and offer our deepest condolences to his family and friends…End dictation."
The echoes of my steps resonated within the expanse of the hospital garage. As I made my way to the end of the aisle to my stall, a couple caught my eye.
A tall man, his hair only beginning to turn grey, faced a woman of similar age, dressed in a beautiful white summer dress. Next to them a car, its trunk agape, half packed with a box of personal belongings and a white plastic bag full of clothes sat waiting. Still, they stood, pausing, ruminating.
They stared longingly into each other’s eyes, a deep seeded pain overwhelming them as tears trickled down their delicate features. A warm embrace as they held each other tightly and wept.
I wondered what terrible tragedy had befell them. Did a loved one’s health take a turn for the worst? Did a loved one just pass away? Did their mother, father, daughter, or son, just perish from this earth? I could not help but wonder.
But it was not my place to ask.
I watched helplessly as they buried their heads in each other’s shoulders and comforted one other.
I continued walking.
My friend, old and passing, said,
“There is more to life than staying alive.
Don’t rescue me too much.”
On his farm, twelve miles out
by rough gravel roads, he is done
with plowing, spraying, harvesting.
But he is not done watching the sun
sink below the windbreak or listening
to the nighthawks above his fields.
Don’t make him move to town.
There is more to tragedy
A Note to His Doctor by Kevin Hadduck.
Poetry and Medicine, JAMA July 2, 2014, Vol 312, No. 1
A narrative piece by docedace.
And I wish I could tell you a story about fancy heroics - about an exploratory laparatomy, a chest thoracostomy, or a patient that coded and I was the last person to perform the chest compressions that brought them back to life. But I can’t. But I can tell you that I saved a life.
For weeks, a patient had been ambivalent, struggling with the decision between full medical care or comfort care only. It was only a matter of time between the disease would make that choice for her.
Everything we could do to prolong her life had been done. There was no process left to reverse. The disease was reaching its ultimate conclusion. With great reluctance, the patient agreed to comfort care.
It pained me to see her struggle because I knew how much it chewed her up inside, to leave behind her family and friends, to be confronted with the threshold of death. It was obvious she loved dearly and was dearly beloved.
I saw her briefly again today after finishing my rounds, passing through our hospice. After seeing her struggle for so many weeks with this decision, I was relieved to find her smiling, having finally found peace in these last hours, surrounded by friends and family. As they gathered to look at old photo albums and share stories under the warm winter glow, her eyes flickered with joy as she laughed with her grandchildren.
For a moment, our eyes met as she caught a glimpse of me by the nursing station. Quietly, we acknowledged each other.
When I was waiting for test results I tried to make up a description in my mind of the consequences of a bad outcome; for myself and then for my wife and my children. For myself it maybe is not too bad - straight to the grave - which is where we all go; even if we think it is too early whenever it comes to that. It is awful, it is difficult to get used to that thought - if you ever are able to…it would be worst for my wife…she is the one who has to take the blow.
When I heard of going to the cancer clinic, I began shivering all over my body. As soon as I opened the door here I felt the smell of the house of death. I can still feel this smell. The word cancer is loaded with fear, I think, and I know some persons who have died of cancer. A tumor is a tumor; uncontrolled cell division, something growing and attacking inner organs.
I react severely to the cytotoxic drugs. I feel so sick, and although I get other drugs to subdue the vomiting, the sick feeling is there, rocking my body all the way. I feel as if I am being run over by a steamroller - my whole body is reacting.
I remember when I woke up from the operation the surgeon told me they had found “islands of outgrowths” in the peritoneum, which was negative news. Something strange happened to me; all anaesthetics and all drugs disappeared from my body, my brain become crystal- clear and I thought: “How can I tell this to my wife?
"Unhook me from these machines. I am going home now and not a moment later."
More than an hour before, I stood by the bedside and watched as the team worked furiously to resuscitate him. Esophageal varices, a cluster of severely dilated and pressurized veins, had been slowly brewing within him over his many years of alcoholism. With the tension of its walls reaching the breaking point, the time bomb had exploded in a torrential gush of blood.