What truly palliates? Do we choose or do we allow the patient to choose?

The day I met Mr. Lightfoot, he was a medical curiosity on teaching rounds, “a great example of a Sister Mary Joseph’s Nodule,” a sign of metastatic stomach cancer. Earl was lying in a hospital bed in the cancer unit of the hospital, his stomach completely distended, nauseous and vomiting, unable to eat anything. He had undergone a cycle of chemotherapy only days before.

I organized Mr. Lightfoot into a problem list:

1. Nausea / vomiting. Zofran and Compazine

2. Diet. IV fluids, PO intake as tolerated

3. Gastric cancer. Status post cycle of chemotherapy, hold for now.

The plan seemed simple.

Over the next few weeks, the treating physician believed the root of Earl’s suffering was the latest round of chemotherapy, and with some supportive medications, he hoped to hit him with a second treatment. My job was to tune him up for the next round.

“Today I ate a lemon ice, and it went down OK,” he would tell me with a sense of accomplishment. Earl was counting his progress in frozen water with some yellow food coloring. I felt my heart ache every time he held that pathetic little paper cup of fluorescent ice, no nourishment inside but only a meager promise of the social and psychological comfort. What did it mean to eat? Cancer robbed his wife of the pride of feeding Earl his favorite meal, it stole the taste and the enjoyment of food out of his mouth, and from his mind, any sense of control over his body. To be unable to eat was an undeniable sign, even to a layperson, that they could not put their health back together again. Doctors call it “failure to thrive.” What a horribly accusatory term. As if Earl was not trying his hardest to keep that stupid lemon ice down, but for the tumor that ate him away from the inside out.

In this setting, his kidneys began to fail. Perhaps it was because he was dehydrated, perhaps it was because he was malnourished and the fluid would no longer stay within his blood vessels, but leak out into the space in his abdomen. Whatever the case was, his potassium began to rise. I had seen his problem list too close, and falsely perceived it to be a neat list, lined up in order of fixable problems. That was the fallacy, for Mr. Lightfoot’s problems were entangled like a spider web: malnourishment connected to kidney failure, vice versa, both connected to his gastric cancer, all connected to pain, discomfort, nausea, vomiting, with death sitting sinisterly in the middle. But what was the best way to die?

Cause of death. I plotted these out in infinite iterations in my head. To dialyze Earl indefinitely to have him starve to death? Or to allow his potassium to rise over the next few days, and have him die of sudden cardiac arrest. We were at a crossroads.

I pulled up a chair in his room and sat down, “Your kidneys are failing, and your potassium is going up. Normally, we would give you some medicine to help you excrete the potassium through your bowel movements, but your stomach is blocked with cancer. We might consider dialysis, but it would be a lot for your body to take. We could try to fix your kidneys, by giving you fluids, but your fluids are leaking into your abdomen, because you cannot eat. We could try to feed you through a tube that goes from your skin into your intestines, but because of the pressure in your abdomen from the fluid, it would not work in the long term.”

At this point, I stopped. I think I intentionally stopped to allow him to process what I said, but in the silence that followed, I reflected on the futility of my monologue.

All of your organs are shutting down, and I cannot fix them. There is only one problem – these organs in your body are just pieces of you, and you are dying. And right now, I need to find the courage to say out loud that which you know.

“Everything I have offered you is a temporary fix, but I can ask for any of those treatments, if you think you would like to try them. None of them will treat the cancer. Or we can make you feel comfortable, and you can go home and spend time with your grandchildren. I can come back in a while if you would like to think things over.” It was a pitiful dance around the truth, but it was the best I could do.

I’d like to say I paused again, for his benefit. But it was because I ran into the locker room around the corner, and cried. I tried to wipe the smeared eyeliner from my face and return to the nurses station, when Mrs. Lightfoot came to me, bravely and sturdily, and said, “How will it happen? I just want to know what to expect.”

“His potassium will rise, and at some point his heart will have a change of rhythm, and it will stop.”

“Will it hurt?”

“I don’t know, but we can give him pain medication to take home with him. Truthfully, he may pass away very suddenly.”

She gave me a hug, and I started to cry, my outward composure be damned.

Mr. Lightfoot taught me about the stigmata of end-stage stomach cancer, the physiology of multi-organ failure, but the greatest lesson I learned from him is that there’s no good way to say good-bye. I have often thought about medicine is not about “saving lives” but about buying time, delaying death, and changing the end of the story – a morbid choose-your-own-adventure. We stave off a heart attack, so patients may die of cancer. We stop the bleeding from a wound, so that they may die of a stroke.

However, in the moments in between, we buy our patients time. Time to spend with family, time to achieve milestones, time to live another day. But in the end, what’s the best way to go? I’m not sure I have a good sense of what the best cause of death is – to be shocked, to be shot, to forget how to exist. And I’m not sure I know if the best cause of death for the patient is the best cause of death for the family. But every so often, I re-read Mr. Lightfoot’s obituary, which doesn’t mention a single organ system, but that he passed away in the company of his family and loved ones.

In arguments regarding death with dignity or physician assisted suicide, we omit a very real truth. We already play God. We choose whether to treat sepsis, or electrolyte abnormalities, or starvation. We make a judgment call that a cardiac death is better than a neurologic death, which is better than a violent death. We select a cause of death that seems most palatable to us, the observing family, and to the patient. So then, what truly palliates? Do we choose or do we allow the patient to choose? By ice or by fire? By drowning or falling? By kidney failure, a heart attack, or by starvation? Or quietly, suddenly, in a dream.

Divya Yerramilli is a radiation oncology resident.

Image credit: Shutterstock.com

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