Mr H should not be dying.
That was all I could think of as I watched this man gasp his
final breaths. Here was a man who should have walked out of the hospital with
some good months ahead, but instead suffered a complication from a procedure and
eventually demised from it.
The Elisabeth Kübler-Ross model of stages of grief
illustrates a series of emotional stages a person experiences in the face of an
unpleasant circumstance. As I reflect on my short stint in Palliative Medicine,
I cannot help but liken my experience to several aspects of this model, albeit
not necessarily in the same order or context. The lives of a few patients whom
I have crossed paths will continue to remain etched in my memory as I continue
to walk this journey of Medicine.
Denial. It cannot be happening to me. Mr K was a young man with
young children and a newly diagnosed lung cancer. Chemotherapy had failed to
arrest the rapid growth of his aggressive tumour and he suffered from relapsing
bouts of pneumonia. As I spoke with him, it was apparent that he rejected all
possibilities of his condition deteriorating. To him, it just could not be. As
I watched him grow dyspnoeic from progressive disease burden and inability to
cope with his diagnosis, I too grew frustrated at being unable to give a good
answer to his questions. Death is never easy to deal with. Most people chose
Medicine as a profession to pursue healing and the sustenance of life. As I
dealt with death and the dying in this rotation, denial came in the form of fixed
belief that Medicine could heal all things. To palliate is to have failed.
Anger. Anger followed naturally from denial. I found myself
being angry when patients continued to deteriorate despite aggressive
treatment. As I grew to appreciate the value of palliation, I remember the wise
words of a particular senior in Medical Oncology. A good oncologist knows when
to give chemotherapy. A great oncologist knows when not to. I soon discovered
for myself that as a junior doctor, persisting with futile treatment was
sometimes a coping mechanism more for myself than for the patient. This only
served to perpetuate the anger in not being able to understand the reason for
sickness and death. In the face of a dying patient, I sometimes felt upset with
myself for not being able to bring about recovery and restore health.
Bargaining. There are same things in life that we are
willing to trade anything for, regardless of cost or sacrifice. I was
particularly moved by a 72-year-old daughter who could not bear to send her 95 year-old
mother to a hospice despite having no means to care for her at home. The
patient had suffered a massive stroke and was left in a vegetative state, being
sustained on nasogastric feeding. As much as the medical team tried to convince
her, this daughter resisted the notion of withdrawing treatment or
institutional care. To her, it was worthwhile for her frail 72-year-old self to
struggle with learning how to change diapers, managing a nasogastric tube and
repositioning her mother regularly, clinging on to the remote possibility of
recovery. As she bargained with the medical team for time and means to care for
her mother, I also learnt to bargain with myself, to consider and understand
that the irrationality of love and filial piety does not negate its purpose and
meaning to an individual.
Depression. There came a point in time where I did feel that
I could not bear to visit Mr H as part of my morning round. Everyone knew that
he had already come to a point of no return – it was a matter of waiting. What
do you say to a dying man? People have warned me that Palliative Medicine is a
“depressing speciality”. This rotation has indeed highlighted the sobering realities
of life and death. For days as Mr H continued to linger on gasping for breath,
I went to work feeling defeated, half hoping that his demise might come quickly
to end his suffering. The day I found that he was no longer a patient on my
inpatient list was the day that brought about some relief.
Acceptance. In the days leading up to Mr H’s death, I had
the chance to sit by his bed for a moment. Instead of asking the usual “are you
breathless today?”, I asked “what do you feel now?”. His reply, “At peace.” In
the course of this rotation, I have come across many different patients who are
at different emotional stages of the Kübler-Ross model. Some people die never
fully understanding or accepting what they lost their lives to. When I heard Mr
H share that he was at peace, it occurred me that that to have come full circle
and reached acceptance about your disease in itself is a blessing. With that,
Mr H closed his eyes and breathed his last. Approaching the end of my posting,
I too discovered the joy of acceptance. Accepting that Medicine cannot have the
answer to all things and that as doctors we are human too makes the practice of
Medicine a little more bearable.
Just a little more bearable. Palliative Medicine makes life,
and hence death, a little more bearable.