Posted by One Friday afternoon one of my partners signed out to me the patients in the ICU. I was taking over and would be going on-call that weekend. One of the patients endorsed to me was the patient in ICU Room 26*. Her story was quite sad, to put it mildly.
She was in her early 40’s and was diagnosed with a very aggressive type of breast cancer, several months back. She had underwent radical surgery, followed by radiation therapy and intensive chemotherapy. However, despite of all the exhaustive interventions, the cancer still proved to be more aggressive than the treatment. It continued to advance.
The cancer had spread to the lungs and pleura (sac around the lungs), causing fluid to accumulate in the pleural space. It also spread into the pericardium (sac around the heart), also causing fluid to build up inside the pericardium. It had involved the liver and studded the peritoneum (lining of the abdominal cavity) as well, causing water to seep out into the abdominal cavity. In fact, the cancer is everywhere, that it was hard to imagine that she was still alive. Well, barely.
For the past couple of months, the patient had been in and out of the hospital, that she literally lives in the hospital than home. Due to multiple complications of the widely metastatic cancer, she had undergone several surgeries and procedures. She had surgery to put a pericardial window (made a hole on the heart sac), so fluid could drain out and would not drown the heart. We also placed tubes on both sides of her chest to drain the fluids around her lungs to prevent her from suffocating. She underwent multiple drainage of the abdominal fluid as well, to decompress her distended, pregnant-like belly.
Several times she thought of throwing in the towel, and considered hospice care. Hospice is the type of care that focuses on comfort and palliation of terminally ill patients. In other words, it is a philosophy allowing a dying and suffering patient to pass on peacefully by letting nature takes it course. Hospice is no way the same as euthanasia, which is illegal in the US. Euthanasia is a subject on its own that I will not divulge in here, but suffice to say that I believe, is morally wrong.
But once she felt a little better she would change her mind and would like to go full court press, and be as aggressive as ever with the treatment again. She was tried on investigational treatment and was even referred to a top cancer center in the US, but had received the same disappointing verdict of “nothing else we can do.”
Now, she was transferred in our ICU for severe shortness of breath. She struggles, but still fights with every breath, clinging for dear life. Still hoping against hope, that somehow she would survive one more day or one more night.
My partner then told me, that if I have time, maybe I could sit down and talk with her, and discuss alternative options of management, like palliative care or even hospice, and the further direction of her care.
We have heard the cliché that it is not quantity but quality that is important. Perhaps you also heard of the adage that it is not how long we live, but how we live is what matters. I am a firm believer that living is different from mere existing. Alive does not always equates with “a life.”
With the modern medical technology nowadays, we can support a person to continue breathing and his/her heart pumping, even though “life” has long been sucked out of the body. Sometimes medicine, as a discipline, do interventions just because we can do it, but may not be necessary for the best interest of an individual.
I believe that there comes a time that death should be received as a repose to the suffering and not always be feared as an unwelcome guest. For death is as natural as birth to all humans. There is a time to be born, and there is a time to die.
The next day, as I made my rounds in the ICU, I was ready with my “heart to heart” talk with our patient. As I entered room 26, I was caught unprepared with the sight I saw.
The patient was silently lying in her bed with her eyes closed. Her breathing was labored as she heaved with every breath. A boy, probably 7 or 8 years of age, whom I assume was her son, was sitting very close to the bed. The boy’s head was buried in bed, muting his sobs, as he leaned against her mother’s side, while her feeble hand gently strokes his head. It was so heart-breaking to witness: a mother who was on borrowed time, and who was in much discomfort, yet still trying to comfort her son.
All the reasonings I have in mind, and the discussions I have prepared, went out the window. Who am I to say to that boy, that his mother’s caressing hand was not worth living anymore here under heaven, even if it just for another day or even for another hour. For that boy, it was still worth it.
I walked out of ICU 26, without uttering a word.
(* room number was intentionally changed for privacy)
Pinoy Transplant in Iowa 
I can’t help but juxtapose this patient’s struggle to live to someone I’ve blogged about a few times. Your patient is someone brave and selfless probably, wanting to cling to life not just for herself but for people she loved. I lost a dear friend last year (someone i grew up with, in fact) to ovarian cancer stage IIIc complicated by a myelodysplastic event in her bone marrow. But throughout her ordeal, she procrastinated because of her unfounded fears, her abhorrence of being in compromised states and appearances, her dysfunctional relationship with her family. Through it all, they showered her with attention and seemingly unending funds. Theirs is one of the out-of-sight wealth in Manila. But none of it was of any use with all the bad choices and the long-winded decision process just to get treatment. so tragic!
I hope your patient will pass on peacefully.
Palliative care, hospice, euthanasia (or whatever people choose to call it)— it’s all in a spectrum, really. As medical professionals, it’s easy to take the path of least resistance and aggressively pursue the preservation of life. But there is also the more important aspects— compassion, dignity in dying, the revelation and coming to terms with reality, Life coming around in full circle.
Yours is not just to be scientific and logical. People don’t realize how humanitarian it is to be in the medical profession until they’ve walked in those shoes.
For doctors, especially for an intensivist, sometimes the hardest lesson to learn is to determine when to put on the brakes.
Very true. “For death is as natural as birth to all humans.There is a time to be born, and a there is a time to die.”
Ang masasabi ko rin ay “Let Go & Let God”. Mahirap at malungkot ang mga pangyayari lalo na ang kamatayan pero ang pananalig sa Maykapal na Siyang nakakaalam at gagabay kung paano natin susuungin ang mga ganitong pangyayari sa ating buhay.
Dinaanan ko rin ang ganyang pangyayari sa aming buhay.
Sangayon ako sa sinabi mo: Let go and let God.
“…living is different from mere existing.” – Indeed!
Hay naku, I’m starting to fall in love with your blog! Hehe! I love reading your posts because I know they were written straight from the heart. I am also in the medical field (I’m a nurse), and I can relate to this post. There are so many times when my heart just breaks for patients who are suffering a lot.
This is very well-written, doc!
I know you can relate very well, as being in the medical profession too. We witness this scenario too often, sad to say.
Aimee your classmate in highschool at Pasay shared to me the link to your blog, I read about 3 to 4 blogs made by you and have to pause after reading this “Time under heaven” This one is a real tear jerker for I am a mother myself…. I can understand why it is hard to say anything, all cards have been played… what’s left is an option to offer a prayer, if not for healing then at least for peace. I do not know if offering a prayer is viewed as sign of weakness by some medical doctors… but I think it can convey empathy. Still I understand why you did not utter a word… uttering a prayer maybe really difficult too in that moment. Most of our patient’s in our ICU are geriatric, they live their life, they spent their time, their exit are usually quiet if not peaceful. It’s different for those we called “Dying Young” I just have to wish and pray that the son of your patient is coping well, my heart goes out for that little boy. I appreciate your blog, you relay your story in a way that is easy for the readers to understand. Thank you for sharing.
I agree with you, that there are many times that we, in medical profession, have nothing much to offer but a prayer of comfort to our patients. And I don’t think that should be viewed as sign of weakness. Thanks for dropping by.