Death, not Dying

by carlocmd

He was 76 years old, and he was dying.

His colon cancer had spread to the lungs and liver.  He underwent surgery two years ago to remove the tumor in his colon.  The stage of his malignancy, according to current guidelines, was in the grey zone — meaning further treatment with chemotherapy was optional, experimental, and could be pursued on a case-to-case basis.

His oncologist advised him to proceed with either standard chemotherapy or a clinical trial.  He was born and bred into the military, and was used to being in charge all the time.  After considering his options carefully, he chose not to have chemotherapy, despite the yearnings of his wife and children.

He was well for the next 18 months, and his follow-ups every 3 months did not show any recurrence of his cancer… until 6 months ago.

There was a small lump on his chest CT scan.  It rapidly progressed in size over the next few weeks, necessitating an admission into the hospital.  A biopsy of the lesion showed that his cancer was back.  There were multiple growing lesions in his liver indicating that the cancer was there too.

After another multidisciplinary conference with his physicians and family, he chose a palliative course.  His objectives were very clear.  Live the rest of his life comfortably.  There should be no pain.  There would be no dialysis (his kidney function was slowly deteriorating).  The family agreed to respect his wishes.

His wife visited the clinic yesterday.

“Doctor,” she began, “he is not in pain.  He is eating.  But he has continued to lose weight.  He is urinating, but his limbs are swollen with fluid.”

“Does he feel ok?” I inquired.

“Yes, he doesn’t complain of anything.  But I hear him coughing at night.  We place him on oxygen and this seems to help him sleep.  But his breathing has changed.  It is noisier and it appears he is breathing from the stomach,” she continued.

As trainees, we associate this pattern of abdominal breathing with patients who are in extremis.  I brought up the idea that these might be his last few moments.

“I’d like to think that we are ready,” she explained.  “We’ve been preparing for that day for months.  I guess I’m here because I want to know what to expect.”

It was not death that she was afraid of, but dying.

I told her that like living, our dying is unique.  In patients with similar conditions, when the liver fails, our patients just fall asleep, lapsing into a quiet coma, until all vital functions cease.  Some patients find difficulty breathing. They may feel some air hunger, which we usually assuage with oxygen and some morphine.

“My son thinks he has pneumonia too, because of his cough,” she said.

We talked about starting antibiotics, understanding that this does not improve his prognosis, but wards off additional suffering from a lung infection.

“We’ve had a good run, didn’t we, doctor?” she said, as we rounded up her visit.  “I am no longer afraid.”