When faced with the diagnosis of cancer in my 80s, would I be able to say, “I had a good life. Just let me go home to spend time with my family?” Well, that’s the courageous decision my patient made during her hospitalization, and I admire her for it.
When I came on inpatient service last week, one of my patients on the list was an 81-year-old lady who had come into the emergency room with intractable nausea and vomiting, and she was subsequently found to have a mass that stemmed from the gallbladder/liver and infiltrated into part of her intestine and completely obstructed her stomach outlet – explaining why she was vomiting so much.
I was told we were in the process of trying to biopsy the mass to find out what kind of cancer this is, so that we can have a better plan for treatment and management. This made sense as the standard management of a mass of unknown origin is to find out what it is before doing anything else, because any intervention that we do prior to biopsy can potentially limit the routes of treatment once the etiology is known. But every time I went to see her, she looked miserable. She had recently lost her son to metastatic bladder cancer, and she had an incredible amount of guilt for missing his funeral that happened during her hospital stay. She also lost her husband to complications of Parkinson’s disease several years earlier. She would say to me, “every time I wake up in the morning and find myself still in the hospital, I ask God, ‘why haven’t you taken me already?'”
The plan was to wait 3-4 days until the surgical oncologist and gastroenterologist came to the hospital to evaluate her and to offer routes of biopsy and treatment plan. That meant she would have to keep the nasogastric tube in her nose for several more days to suck out all of the stomach contents. And depending on the results of the biopsy, which would take several days to result, she would potentially stay additional days depending on whether surgical intervention or chemoradiation is recommended for treatment. Oh, and she would need to get nutrition through a special IV line, which is notorious for causing all kinds of trouble.
But I started doubting this direction of management. It was clear to me that she was miserable in the hospital, absolutely hated that tube in her nose, and she just wanted to be home with her family.
So I went in the room and sat down. I laid out for her the current plan, what the ramifications would be, and my concerns that our recommended plan is not aligned with her priorities. I told her if we wait to get a biopsy, the most likely treatment options would be either a surgery or a chemoradiation therapy. She could not bear to think about a surgery at 81 years of age, and she had also seen her son suffer through chemoradiation, and she did not want to go through that to have a chance to live a few more months longer. She felt that these treatment options can prolong life but will reduce her quality of life – which I couldn’t disagree with.
She said, “I’m lucky to have had a good life, and I just want to get this tube out of my nose and be with my family. I don’t need to know what is growing inside me. I just want to spend the days I have left at home with my family.”
Hearing that from her, we completely changed our plan. In order to get the tube out, we arranged for her to get something called a gastrojejunostomy tube that created a connection between her stomach and her intestines, so that we can bypass the obstruction and allow her stomach contents to drain out, keeping her from vomiting, and ensure a route for tube feeding, eliminating the need for IV nutrition.
After developing this new plan together with her, her eyes brightened up and I saw her smile for the first time. Her family was fully respectful of her wishes, even if this meant that they may have less days left with her. They wanted to prioritize her comfort, and they knew this was the better way. My patient told me at the end of our conversation, “I think God is working through you to guide me.”
Imagining myself in 50-60 years, would I be able to say the same thing and make the same choice? Would I have family members crying for me from both sorrow and joy, supporting my decision and celebrating the end of my life? She said she was lucky to have had a good life, but she also had lost her son and her husband to terrible diseases, spending a good amount of her life being a caregiver to dying family members. Yet, she had a deep sense of peace and gratitude. Did it come from all the tribulations she experienced in life?
I hope I can make the same decision if and when that time comes for me.
hayoungyoun 