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All clinical cases that thrive on the cusp of life and death invariably give birth to perplexing questions: Different stakeholders – whether patients, family members, and acquaintances or doctors, nurses, and medical staff - have to deal with life and death situations where the outcome can (and at times does) turn towards either end in the unlikeliest of ways. In the third edition of “Oasis”, we probe deeper into this critical issue, which is needlessly made to appear dark and sinister in conventional conversations.
Here goes…
When, according to you, does death become a better solution?
That’s a good question to kick-off our conversations. You mentioned euthanasia above. A lot of our terminally ill patients wish for passive euthanasia as they find resuscitation meaningless at the point of no return, which they may have internally sensed. They may have had a knock at the door like in the movie “Meet Joe Black”, where Brad Pitt meticulously leads Anthony Hopkins to ask the primordial question, “Am I going to die?”
Death at that point seems inevitable and imminent, and any intervention clearly does not add to the quality of life, although it may or may not add to the quantity of life. More importantly, resisting death also proves infeasible from the financial perspective which is an integral part of the treatment and often proves prohibitive. In many such cases, death becomes a better solution than life, not as a meek surrender but as a conscious embrace.
What has been your personal experience on this front, as a surgical oncologist?
In my evolution as an oncologist, I have grappled with many fundamental questions, especially during the formative years: why do a few good cancers go bad when the doctors assumed a recovery track in due course? Conversely, why do a few bad cancers miraculously transform into good cancers saving lives when all clinical hope had been abandoned. When I did not find credible and consistent answers from all likely sources, I turned to the Bhagwad Geeta to help me address these existential questions. I cannot say I found the answers in the sacred text, but I definitely understand the questions better than before.
You are an agnostic, right?
Yes! As an agnostic, neither a believer nor a non-believer, I respect all religions and deities. Being a man of science, beliefs for me are nothing but hard facts. Like for instance, I see sun and the moon every day and hence I know they exist, I do not have to force myself into a belief without knowing it to be true. I find God and spirituality synonymous with science as natural laws deriving their fundamentals from a blend of facts and hypotheses, which have been accepted as truths. Having said that, as we probe deeper into things, our assumptions of truths change. And that is where we should ideally seek refuge in the Socratic truth: “the only thing I know is that I know nothing.”
How do assumptions of truth change in the course of the treatment?
As physicians, we encounter death on a daily basis, complete with the suffering and misery that it invariably triggers. At the same time, we also experience mystical U-turns where a patient comes back from the point of no return. Imminent death can have an aspect of life hovering around it and vice versa. During such transcendent experiences, the doctor is venturing into uncharted territories. I have a long list of absolutely baffling cases: some have left me emotionally drained; others have given me dollops of joy, hope, and inspiration, a few have lent me deep insights into the play of life and death, while many others have forced me to re-examine some of the assumptions that I held dear till that point.
Let us take a closer look at all these cases in your words, for the benefit of the reader:
I met Dr. Stanley Wetschler, former director of the Bradfordwoods Medical Centre, through sheer serendipity. Save for a common acquaintance between us, we were as good as strangers, and yet he graciously decided to host me at his lavish Pittsburgh residence when I moved from San Francisco on a Pittsburgh University stint. During one of our heartfelt conversations, he casually shared his medical report with me and asked for my opinion. It was a case of stage four colon cancer; the tumour was clearly not responding to chemotherapy. I could barely convey my helplessness to him as any intervention at that stage seemed pointless. He smiled and showed me the date of the report, which was ten years back in time. I was flabbergasted when I realized that the good doctor had not just outlived the six months his doctors had then given him, he was in the pink of health leading a perfectly normal life.
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A 67-year-old lady patient came to me in 2015 with an aggressive cancer of the mouth, a sarcomatous carcinoma of the maxilla. Post an eight-hour successful surgery, when she came back in a month’s time for radiation and chemo, the tumour had recurred both in the lungs and local area. The patient was now in a wheelchair, unable to walk on her own.
Notwithstanding the seeming futility of further treatment given the poor prognosis, I briefed the patient about metronomic chemotherapy – a low-dose chemo variant founded on the simple premise that if you cannot demolish a building at one go, try to remove one block at a time, akin to the brick removal in the film ‘Shawshank Redemption.’
I gave her the needful tablets and requested her to keep me updated through regular follow ups. One and a half years later, when she came back, she was doing fine and was back to normal life. A PET scan showed no tumour this time around. I was overjoyed to see our prediction going wrong; we had given her not more than a month after she had first come for radiation and chemo, and here she was, urging me for a cosmetic correction to set her face right with the vigour and vitality of a young woman.
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Another patient of mine, a cancer survivor, was having her stiches removed post-surgery. She seemed incredibly happy and upbeat, thanking me for helping her conquer the disease. I reassured her and asked her to return in a week’s time for routine follow up. She happily bade me goodbye and went to the washroom to freshen up. Then and there, she suffered a massive cardiac arrest that claimed her life on the spot.
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A 65-year-old lady was doing well after surgery, but a minor infection delayed her overall recovery by five days. During that time, I came to know that none of her children wanted her back home as they saw her more of a burden. She seemed extremely depressed despite the recovery. At night, she passed away in sleep but just before that, she called the nurse and narrated a beautiful scenario that she was visualizing, that she is in her hometown, laughing in the fields, enjoying the bliss of mother nature with gay abandon. After the narration, she had a hearty laugh before she closed her eyes forever.
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On one my routine ICU rounds, a lady approached me, the daughter of an old patient of mine whose condition was deteriorating by the minute. She requested me to give a courtesy visit to her mom in the ICU. Having undergone tracheostomy, the patient was breathing though a hole in the throat and feeding through a stomach pipe, while her bladder was being emptied through a catheter. The tumour had spread all over her body and she was in discernibly bad shape. She wrote a note asking me: ‘how much time do I have?’ I told her instinctively that I was not sure, but it was not more than a day or two. I vividly remember the bright smile that adorned her dull face. She was overjoyed and wrote another lovely note to me, thanking me for telling her the truth when everybody around her was busy giving her false hopes. She moved on with a deep sense of solace writ on her dying face.
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A cancer patient of mine, a young and dynamic sports journalist, was known to me since long. I had even played a part in arranging for his matrimony. Since he had lost his voice box, his marriage seemed a difficult proposition although the girl loved him. I convinced the parents on both sides to let the wedding happen given the deep love between the couple. The girl’s family asked me bluntly about his life span: I asked them a counter question: what about your life span? Can you make a prediction? Just because he is a cancer survivor does not mean we can predict his impending death. So go with the flow and who knows, he may outlive you, I told them.
Ten years later, his tumour recurred and spread to the lungs. We managed to stop the profuse bleeding for a while but after a few days, he was again critical. Soon after, I got a call that one of last wishes was to talk to me. When I went to his room, he was about to be put on the ventilator. The medical team briefly reversed the sedation, and he gave me a thumbs up for a goodbye.
I was examining his reports while the medical team informed me that all that could be done had been done. Yet, I decided to make one last attempt of manually putting pressure on the concerned area. The next morning, I was told that the bleeding had stopped. The week after, the ventilator was removed as he was showing signs of waking up. Three days later, he was looking in much better shape and was shifted back to his room. As per his wish, he was allowed to spend time with his three-year old daughter and also complete his unfinished book on cricket.
Not only did he complete the book, but he also hosted a grand book release function. His normal life resumed for a while, but sadly the tumour came back with a vengeance. When he met me again in my OPD, he was visibly depressed. Amid his worsening condition, he was also forced to face the onslaught of the constant bickering between his mom and wife.
Being helpless and hapless, I intuitively decided to employ humour to cheer him up. I told him “Even Lord Shiva and Lord Vishnu failed to resolve this sticky familial challenge, why do you grieve unless you feel you are above these gods?” I was happy to see the smile back on his handsome face. I told him to go back home and send me a clean-shaven snap. He sent me the snap and also conveyed that he felt better after talking to me. He passed away few months later.
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A patient from the Northeast was due for discharge in a week’s time. All of a sudden, he suffered a severe psychiatric attack with no history of similar episodes. He became violent to the extent of physically attacking our hospital staff on duty. Metabolically, the psychosis could have the outcome of carbon di oxide retention or tobacco withdrawal, but the exact cause remains unknown. When he collapsed in a breathless state, he was immediately taken for resuscitation. After the tracheostomy, his breathing resumed but his pulse and cardiac rates remained unstable, and his ejection fractions were not strong. On an impulse, I touched the patient and made a silent prayer. All I asked for was the right guidance from above as I did not know what was best for him. As I walked towards the next ICU bed, I saw the wife of this patient, understandably distraught and broken down. Something inside me urged me to talk to her. I told her about his deteriorating condition and asked her to let go. I told her every therapy has failed, his body has given up, and we are forcing him to come back. About three hours later, I came to know that he had moved on. But, after a few hours, I was duly informed that he had reclaimed his life from the jaws of death. I will never know what exactly transpired in those wee hours, but this patient fully recovered and went back home smiling.
What explains such miraculous recoveries and relapses?
This question has no answer, but it should not deter one from analyzing these statistical outliers to guide future therapies, as also study life and death from all the perspectives discussed above - ethical, legal, scientific, and spiritual.
When a stage IV cancer patient asks me, “Am I going to die?”, my answer is that we did not choose the day we were born, likewise, we cannot decide the day and time of our death. What we have at our disposal is the time and space in between. In this space, there is science, there are facts and truths beyond which there are assumptions of truths. As clinicians, we have to operate within this spectrum which is why you must have your Intelligence Quotient, Emotional Quotient, and Spiritual Quotient tightly coupled with each other. All three have their own ways and means to guide you and you cannot ignore any of them.
A lot of the times, death has a few emotional entanglements and how it chooses its way out is too intricate for human understanding, whether you call it Karma or anything else. It is easy to seek refuge in the good karma -bad karma theory, but I feel, sometimes, many good people absorb the negativity around them in the form of cancer afflictions and move on to make the world a better place than before. Little children are known to do this from time to time, in the capacity of little angels. What should be the surgeon’s approach, outlook, and priorities during such extreme encounters – both favorable and fatal. A clinician cannot predict the time of death. But it is important to explain his or her understanding of death to patients and their kin. My understanding as an agnostic oncologist is that people die to move on and again come back to the universe to interact with each other in differing relationships. During this difficult time when life is ebbing, patients should get as much good sleep as possible. They must also be urged to have food to the extent possible, and all effort must be made to remove their physical and psychological pain, again to the extent possible. Beyond this, nothing is in our control as to what course the cancer will take. Sadly, doctors bear the brunt of undesirable outcomes many a times, as the grieving families finds an easy target to take out their deep frustration and disappointment at having lost their near and dear ones. This eventuality is an integral part of our fraternity. Barring exceptions, no doctor would consciously push a patient towards death. He or she will leave no stone unturned to save a life. It is imperative to communicate with the patient’s family in timely fashion, informing them about the circumstances surrounding the demise. I have set up a bereavement team which swings into action in cohesive fashion every time there is a demise, helping the patient’s family cope with the tragedy, informing relatives, calling for the ambulance, facilitating the last rites and prayers, and attending to paperwork and other formalities. Sadly, a surgeon cannot but escape a ghastly predicament: “How do I go and convey bad news to the family who are hoping against hope?” it is easy to explain the umpteen challenges of life and survival to a patient’s relatives, but it is exceedingly difficult to explain death and its mysterious ways to them. A lot of the time doctors find it difficult to accept their failures or the fatalities of nature. It is difficult to confront death saying that ‘this is beyond me’. It is annoying and over consuming. Do you find it difficult to overcome grief following a tragic event? Yes, I have experienced many such difficult moments. Contrary to popular notion, even oncologists need to undergo a catharsis of evolved processes to overcome the grief that stems from the sheer helplessness in trying to rescue the patient from the jaws of death. My family has helped me burn this catharsis from time to time. Every time I experience a tragic event, they help me to come out of it. Sometimes, a doctor may even need the help of a psychologist to come out of the shock and move on. At times, when I am supposedly counselling the deceased’s family, I have found them reassuring me instead. Many of them have shown extreme forbearance in expressing their gratitude for the attention and care I had shown for the patient even in their moment of grief. Any parting thoughts? A spiritual master once told me, “There are hundreds of people waiting for you outside your cabin. Their blessings and prayers have given you the healing touch. This is not some intrinsic power bestowed upon few individuals by the almighty; it is an elemental power that emanates from the blessings of these common people. This power is not meant to benefit you, it is meant to benefit people. So, make it a point to touch your patients and pave the way for the healing to happen. When you touch them, you offer a silent prayer for their wellbeing.” Ever since, I never forget to touch the patient and offer a silent prayer even if the case is hopelessly critical, like I did in the case of the patient who suffered the sudden psychiatric episode. Even when a patient is unconscious, the soul is supposed to be awake, and it communicates in strange ways. I place my faith in this assumption of truth as a conscious choice. |