Shivering Tulips

Arctic blast is back in our area. After a few days of relatively warm days with some melting in our piles of snow, our temperature is again in single digits (Fahrenheit). The next few days does not look encouraging either. Afterall, we are still in the thick of winter.

As I was seeing patients in our clinic today, one of the constant small talk that I have with my patients is the cold weather. With most of my patients having significant pulmonary condition, this subfreezing temperature is such a struggle for them. My parting shot with them as they get out the door is “stay warm!”

The last patient I had this morning was someone who had been followed in our clinic for more than ten years. Ten years is more of a rarity to be followed by us, as most of them are with advanced lung disease and thus they do not last that long.

He is an old sweet man with a sunny disposition, but crippled with severe COPD, and had been oxygen-dependent for several years now. Damn cigarettes!

He is on maximum medications, inhalers and nebulizers we can place him on, but despite of that, he admits that minimal exertion, or even talking, makes him short of breath. Though he said that not talking much is probably good for him, as his wife who always accompanies him on his visits, laughed with his confession.

As we talked about the deep freeze, he stated that it was too cold outside that the “tulips were shivering.” I told him that it was not yet spring, and so it was not time for the tulips to get out anyway.

When I asked him how he was doing, he said that he was “ready to be planted.”

Was he still talking about the tulips? Or did he mean being “planted 6 feet under ground?”

I know he understands that we have not much to offer him, yet he always come to his appointments, even just to chat with me and my nursing staff. Sometimes I feel that a plain doctor visit gives some of our patients a chance to get off their mundane schedule and provide something to take their mind off their existential misery temporarily. And by merely showing up in our clinic, they let us know that they are still alive.

Don’t get me wrong, I am happy to see them. I know as well, that they are happy to be seen. Or perhaps they are happy just to be here.

Knowing that his condition will only get worse, our discussions wandered to what his advance directives might be. He said that if it comes to a point that he cannot breathe on his own, he does not want to be placed on a ventilator or a machine to keep him alive; and if his heart stops, he said that he does not want to be resuscitated. In other words, he just want to go gently and naturally into the night.

I even offered that I can refer him to Palliative Care Medicine or even Hospice, but he said that he was satisfied with my management and did not feel we need to do anything else at this time.

As I walked out of the exam room, I called out to him, “stay warm!”

He looked at me meaningfully, as if he expects something more.

Quickly realizing my comment, I said that I wanted him to “stay warm” from this arctic temperature. To “stay warm,” that is to keep his sweet and positive disposition. And to “stay warm,” that means staying alive and warm-blooded, and being above ground.

With that I added “I’ll see you in spring.”  I hope the tulips will not be shivering. Nor weeping.


(*image from


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)