Auld Lang Syne

I was on-call that New Year’s Eve. As I remember it, even though it was the holiday season and no patient wants to be in the hospital, it was still very busy for us.

It was a time of a bad flu season and our ICU was full. In fact there was even a pandemic that year of a bad strain of influenza A, the H1N1, or otherwise known as “swine flu,” and we had confirmed cases in our hospital. The hog farmers here in Iowa detest the name “swine flu,” as it was detrimental to their trade.

Despite of my toxic duty, I was able to finish my rounds and saw all our hospital patients for the day (took me 12 hours or so), and made it just in time to a gathering of some Filipino friends for the New Year’s party.

I was only warming up with our friends when I was called for a “stat” consult that I have to see right away. Before I left, my friends told me that if I finish the consult and it was still before midnight, then I should come back to the party. It was around 10 o’clock when I drove back to the hospital.

The patient that I came back for was a woman in her 40’s. She had breast cancer and sad to say, despite all the surgery, radiation, and chemotherapy that she underwent, the cancer had spread to the lungs and pleura (covering of the lungs).

The patient was obviously struggling to breathe when I examined her. The chest x-ray that was done that night, which was requested by the oncologist showed hydropneumothorax. That means there was collection of fluid and air in the space surrounding the lungs. And that was the reason I was consulted, to surgically place an additional chest tube (as she already had one in place) to drain the fluid and air.

After reviewing the chest film and comparing it to the previous chest x-rays, I determined that the finding of hydropneumothorax was old. In fact the chest x-ray was unchanged compared to films from few weeks ago.

That meant that the worsening of the patient’s respiratory status was not from the collection of air and fluid primarily. Placing another chest tube would not matter as the lung was trapped and would not expand further. I surmised that her further deterioration was from the advancing cancer itself.

Maybe the patient and her family was hoping against hope that there was still something that can be done. Maybe they were grasping for straws for a possibility that she could see another New Year.

I explained my findings and I then solemnly, but respectfully told them that in my viewpoint, placing another chest tube would not matter, and that would not relieve her breathing difficulty.

Right after hearing my opinion, that was when the patient and her husband made the somber decision that it was time. Time to end it all. Time to let go. Time to transition to comfort measures only. It was time for her to rest.

The patient’s husband went out briefly, maybe to talk with other family members who were outside the room. When he came back, I bid them goodbye and left.

As I went out of the room I saw two girls, both were probably not older than 12 years of age. They were crying, while an older woman was comforting them. I assumed those young girls were the patient’s daughters. I think it would be safe to say that they were not having a “happy” new year’s eve.

I looked at my watch. It was less than an hour to midnight.

By that time the rest of the world was partying while waiting for some fancy ball to drop. At that time most people were celebrating while waiting to welcome the New Year. While another family was also waiting. Waiting for suffering to end. Waiting not to welcome, but to say their final goodbyes.

I did not go back to the party. I went straight home to reflect, while the song Auld Lang Syne (translated as Times Gone By) echoed in my head.

Should old acquaintance be forgot,
and never thought upon;
The flames of love extinguished,
and fully past and gone:
Is thy sweet heart now grown so cold,
that loving breast of thine;
That thou canst never once reflect
On auld lang syne.

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(*Auld Lang Syne is traditionally sang to celebrate New Year at the stroke of midnight, but it is also sang in graduations and funerals.)

(**photo taken by my wife in our backyard)

Time Under Heaven

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)