I read the chart. I read the notes from the cancer clinic. Call it morbid curiosity — I call it chart review. Either way, she’s fucked.
She’s young. In her 50s, she’s smoked for years, in a region where radon has only recently become something worth educating the public about. English isn’t her first language, and neither is it her family’s.
She was diagnosed sometime around 2009, lung cancer. It’s untreatable with surgical resection, they tried radiation, even though her type doesn’t usually respond well to it. They treated her with first, second, third-line chemotherapy. A recent CT scan told her cancer doctor it had spread… to bones, to other organs, to lymph nodes. There’s lumps growing she can feel herself, and tell the cancer doctor if they’re growing bigger. They try a fourth-line chemotherapy agent, something palliative. They tell her, and her husband, that the cancer has spread, despite a year of debilitating, nauseating treatments. They are, “understandably distressed.”
She comes into the emergency department with signs of infection. Her lungs are somewhat compromised by the fact that there’s a tumor obstructing part of one lung. Her infection plus, god-knows-what, affect her lungs in such a way that I’m MacGyvering various ways in which I can keep her oxygen levels in some range that is compatible with life. The point becomes clearly made to us, throughout the day, that if she’s not going to die tomorrow, she’s going to end up intubated.
The intensivist explains to the patient, and her family, what is necessary. Unfortunately, due to the nature of being the doctor-in-charge-of-everybody-sickest-in-the-hospital, the explanation is somewhat harried and unclear. The explanation falls to the rest of us, the so-called “healthcare team,” to explain what’s necessary for the next few days. “There is a chance,” I say, “and not a small chance, that she may never end up off of life support,” I explain. I ascertain that what she wants is to be supported in the short term. I ensure that I understand clearly her wishes regarding the long term — that her life not be artificially prolonged, should we give her her week-or-so’s duration of ‘rallying time’ and determine, after a week’s worth of life support and drugs and everything-that-can-be-provided, that things are not improving. I ensure that her family, her husband, her children, her mother, understand that this is a very difficult decision to be made in the week-or-so to come, should things not improve. I try and be clear — English is not their first language either. She is very clear, herself — she wants to be kept comfortable, should what is killing her today turn out to be her cancer, and not the infection that we can treat with powerful drugs in a week-or-so.
They understood me. In no uncertain terms, they knew that this may be the last time they ever got to see her awake, and talking. This gave her husband the courage to ask the intensivist — a gruff and imposing man — for some time so that her daughter could come and see her before she became unable to speak. The intensivist has other priorities — either she ends up on the ventilator now or in a couple hours’ time, it won’t make a difference really as to the outcome since she is not yet at the point of crashing. The intensivist will return, and in that time, we-the-ICU-staff will do our best to ensure that should these be her last moments of wakefulness, they will be as meaningful as can reasonably be expected under the circumstances.
We bend the rules — two people in a patient room max, nobody under the age of 16 years, nobody after 8pm. We call their spiritual guide of choice. We are spiritually rewarded, ourselves — treated, somewhat bittersweetly, to the sight of her entire family in that tiny room, hands joined, chanting prayers together in their language.
This is a story that I don’t know the end of yet. It was a hard thing to be close to that much pain. That said, I feel better knowing that even if the story has a really shitty ending, that at least she had a chance to tell her family how much she loves them before she died.