She rings at the recommendation of a colleague who knows my interest in lung cancer and palliative care. ‘It is about my father, doctor’. I suggest that she brings me his films and tests for a briefing before I get to meet him. We arrange an appointment, and she comes with her two brothers, all concerned. I review the history. A couple of months ago the patient, a retired blue collar worker in his late sixties, a heavy smoker, had some unsteadiness and a fall. His scan showed multiple brain lesions, and he had radiotherapy for those. A search for the primary disclosed a lung mass with nodes, but bronchoscopy and biopsies were inconclusive. How is he now? Weak on the right side, some speech disturbance, otherwise okay. ‘What shall we do next?’ I arrange to see him at home.
Two days later I call at his place. Three floors up, no elevator: a satisfactory exercise test for me, an additional limitation for the patient, if he is ever able to move. He has an established right hemiplegia and some motor dysphasia, but looks generally well, with no other abnormal findings on examination. Good respiration, good oxygen saturation, participates in discussion. I would consider a repeat bronchoscopy for histological confirmation. Practical problems: he is on antiplatelet agents, will need an ambulance for transfer (not very easy to organize in the current tight financial climate), will probably have to be admitted for a day. I’ll discuss the logistics with my hospital colleague. Call you soon.
My invasive colleague asks to see the CT scan himself, so I send the family to him. Following the review his opinion is to do nothing active but confine ourselves to supportive care only. I am all too ready to concur: it is reassuring to have support on such a decision by another expert. The family agrees, and this is a relief. Being pragmatic about a difficult situation allows for overall acceptance and facilitates communication with everybody. We leave things at that, and keep our lines open.
Two weeks later I am asked to see him at home again. There has been a change—he is now confused, disoriented, does not want to eat, in general decline. What is the rule of thumb? If the patient deteriorates from week to week the prognosis is measured in weeks; if he declines from day to day we are thinking in terms of days. His oxygen is now borderline at 90 percent, but he has no particular discomfort. I explain to the ever-present family that they must ‘sail with the tide’: there is nothing to gain by force feeding, or by unnecessary medications. We can stop the antiplatelets, the statin, the antihypertensive—they have had their day, they no longer prevent anything. ‘Doctor, what do we do if—?’ the question is left hanging. I promise to come and pull the curtain.
My cell phone rings in exactly one week, in the midst of a particularly busy morning. It is the older son: ‘My mother just called: he does not seem to be breathing’. I will be there as soon as I can extricate myself from other engagements. I work at the other end of the city, and the midday traffic is taxing, but I manage to reach them in about an hour. He is quite cold already. Since last night he had not responded to voice and had not opened his eyes at all, gently edging his way out of this world. Then this morning the wife left his bedside for a few minutes to make a cup of coffee and returned to find him, literally, breathless. No acute event, no sound, no further suffering, just like that: a candle that barely flickered before, now flameless. I offer my condolences, go through the necessary medical motions, fail to elicit any signs of life, pronounce him officially departed. I pull out a death certificate form, sit down at the kitchen table and fill it in, accept a glass of cold water, offer my sympathy again along with the receipt for my fee, walk down the stairs as the funeral attendants climb up to take over. From the balcony one of the sons hails me just before I climb into the car. I wait for him to join me at the sidewalk. Apparently the funeral attendant says that the official form has only recently been changed—how long is it since I last signed somebody off? He has got the new one, so can I rewrite the whole thing? Reluctantly I repeat the exercise test—my fitness improves by a quantum. You’d think that the bureaucracy would be getting less, but no such luck: I need to fill in ID number, tax number, insurance number, and the whole family tree, not to mention the name of the neighborhood, borough, city, state and province. Is all this really the doctor’s duty? ‘Please initial that correction, it’s the law’. Sign and rubber stamp, finished. Another glass of water. RIP.
ANTHONY PAPAGIANNIS, MD, MRCP(UK), DipPallMed, FCCP is a practicing pulmonologist in Thessaloniki, Greece. He received his MD degree from the Aristotle University of Thessaloniki Medical School in 1981. He trained in Internal Medicine in Greece and subsequently in the United Kingdom, and specialized in Pulmonary Medicine. He also holds a postgraduate Diploma in Palliative Medicine from the University of Cardiff, Wales, UK. He is a postgraduate instructor in palliative medicine in the University of Thessaly, Larissa, Greece.