The other day I was re-consulted on a lady I knew from last month. She initially presented with weight loss, abdominal distention, and pain. The work-up showed a distal large bowel obstruction, a large pancreatic mass, and multiple liver metastases. The primary issue at the time was the colon obstruction; she was quite tender and was developing a leukocytosis. I explored her and found some sort of hard, fibrotic mass down in the pelvis. I couldn't differentiate rectum from gyne organs from bladder, so I simply gave her a loop sigmoid colostomy. Intra-operative biopsies of the pancreas and liver unfortunately revealed poorly differentiated adenocarcinoma. She was pretty much cooked. But at least she was diverted and could conceivably live out the rest of her days comfortably.
She returned a month later with abdominal distention and emesis. The CT scan this time suggested a high grade small bowel obstruction. We put in a NG tube and watched her. The she removed the NG and refused to have it put back. Her abdomen remained distended and she started to have pain. Every day, she looked a little worse, a little more beaten. Finally, the pain intensified, she was asking for morphine every half hour, and her WBC count crept up near 18k. Obviously, she needed an operation for definitive treatment but she'd been consistently refusing invasive procedures for the past several days. She had a terminal illness. Doing nothing was an understandable option. I spent a long time talking to the family, informing them and her of the options. You're in a bad way, I said. You're in no condition to tolerate another major abdominal operation, but dying from a bowel obstruction isn't pleasant either. I sat on the edge of her bed while her family crowded around, her husband in a chair holding her hand across from me. These moments in medicine are so raw and private and absolutely pure. As doctors, we are privileged to be able to participate in these intimate discussions of life and death. Almost like voyeurs, we walk into their lives when they are most vulnerable, when all pretense is washed away and the very essence of one's existence is at stake, and they welcome our presence, stranger that we are, because they need us there........She looked at her kids, then her husband. I can't do it anymore, she says. I just can't. I'm tired of it all. I want to rest. Can't you just give me something for the pain....
Her husband's head dropped and he squeezed her pale thin hand even tighter. Sure honey he said, his voicing barely holding together. We can do that. Right doctor? I nodded my head and rose slowly from the bed. Silently, I made my way out of the room; my privileged time had come to an end.
Wow, It's these times that are so hard for families and doctors. I have been in similar conversations twice in my life, right before losing both my parents.
Thank goodness you are there helping this family.
excellent post; sometimes doing nothing is the hardest choice, but it was her choice.
What a sad, hard story. I don't know how you do it. One of my biggest diversions to becoming a Dr. is exactly this scenario. It is hard to fathom while one is healthy, that there can actually come a time where you look forward to the peace and rest that we hope death will bring.
well said, and absolutely true.
recently i did two operations for malignant obstruction. one went well and the patient recovered and is doing well. the second was an open, look around at a frozen abdomen because of extensive mets and close without doing anything. patient insisted on the operation, but it would have been better to do nothing. oh well...
You captured the pain and privilege well. I'm not sure what it is that makes us want to be in these situations, but we can do good, I think.
Our palliative care team always says, giving up on a cure doesn't mean giving up on care.
Did you (or anyone) bring up the inevitable "venting G-tube"? My point being not that G-tubes are very good solution for this problem but part of the "alternative" discussion which we are so implored to explore with patients. (I am exploring a patient tomorrow for gyn/onc who has a malignant bowel obstruction)
Where are the caring surgeons/ doctors like that...
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