Managing The Inevitable

Mitch was the picture of health, in the prime of his life.  Successful professionally, a dedicated father to his young daughter, and a role model to many of his more junior colleagues, who were frequently inspired by his inexhaustible enthusiasm to share his knowledge and expertise.  He kept in good shape, didn't smoke or drink heavily, and exercised regularly.  Life was good.

He had felt some pain in his abdomen for a month or two; nothing serious, just an annoyance more than anything, but it hadn't gone away and he had gone to his Doctor to see if there was anything he should do about it. 

After a month or two of some tests done as an outpatient, the pain was still there.  He had lost some weight without trying, and one of the specialists in hospital organised a scan of his abdomen.  The answer was found - cancer of the pancreas.  Life, as he knew it, had ended. 

The following six months were spent in a series of dreadful scenarios.  Mentally preparing for death, trying to establish a legacy of memory for his daughter, choosing between - six cycles of toxic chemotherapy which wipes you out for three or four days at a time versus two, maybe three months less time alive.  All the while trying to remain strong for his family and friends, trying to get the most out of each day while the cancer destroyed him from the inside out.

Seven months after diagnosis, he is a shell of his former self.  He has been determined to stay at home for as long as possible, and has expressed his wishes to be cared for there, but late one evening, his pain has become unbearable, and his breathing is very laboured.  His family can't bear to see him like this, and he is desperate for some comfort, so they make the decision to come to the Emergency Department.

He is taken into our resuscitation room when the triage nurse sees him arrive.  He is barely conscious, his skin is thin and transparent, stretched tightly over his abdomen and his bony thin face, with a deep sallow yellow tinge that points to a build up of bile in the body, a sign of liver failure.  His pulse is fast, irregular and thready.  He is breathing twice as fast as he should do and his oxygen levels are low.  He groans in agony from his belly and back.

There is no doubt that Mitch is in the final moments of his life.  If there was any medical chance that he could survive this episode, then we would have leapt into action and attempted every intervention possible to attempt to achieve this.  This is always our default position and is a strong instinct in anyone who works in healthcare.  But in this case, we have to make the more difficult decision and prioritise the comfort and symptom-control for Mitch.  Rather than administering treatments for saving Mitch's life, we will tailor therapy to improve his death.

The first stage in this process is talking to his wife and daughter.  This is always a horrible discussion, no matter how often you do it, as it is so hard to predict how receptive families are to confronting the inevitable. 

Sometimes it is something of a release of pressure for them - a sense that the purgatory they have been living in may finally be coming to an end.  When the families and their dynamics are large and complex, it can become an epic undertaking.

Fortunately, Mitch has not missed the opportunity to discuss this prior to his deterioration with his family.  They are well-prepared, and agree that we should make him as comfortable as possible.  He has some intravenous fluids for hydration, mouth washes, oxygen to relieve his difficulty in breathing, and painkillers for comfort.  Mitch dies two hours later with his family by his side –not how anyone would have wished, but as bearable as we can make it.


Saving lives, but not this one

People often see the Emergency Department as a mixture of the glamorous lifesaving activity with the more comical bucket-on-head type patients.  It is rarely either and, with our ageing population and demands on our health services, it is frequently an integral part in palliative and terminal care.  This is no less important a role and one that we take incredibly seriously. 

The ability to diagnose a rapidly terminal condition, understand the likelihood of success of interventions in the context of the disease process, and give a balanced explanation to the patient and the family in quick-time requires many different skills. 

It also gives the Emergency Department team the chance to make death, which comes to us all, more bearable. More importantly, to give the loved ones of patients a memory of the event that allows them to move on, and not limit their future. Lives saved indeed.