Catch-22: A Story of the Impossible Choices Faced by Patients Battling Cancer
HEART OF A DOCTOR
Pavitra Krishnamani, MD MS
“40
-something year old woman, history of metastatic breast cancer, now with pneumoperitoneum likely secondary to hollow viscus perforation. Surgery consulted, dispo based on recs.” The patient was uneventfully signed out to me that night. I knew I was in for a long shift, but the ED looked relatively quiet. My patients were “tucked away” nicely, which means they were waiting for scan results or recommendations from consultants. I signed up to see some of the new folks waiting for a doctor to evaluate them. After I spoke with one of them, Surgery caught me in the hallway.
She lay there, breathing hard and inhaling oxygen from a nasal cannula, clearly in pain from the inflammation and buildup of air in her abdomen. Her belly looked swollen against her thin frame, physically making it difficult for her to take a deep breath. She had a wet cloth laying on her forehead to make her more comfortable. Swaddled in blankets, she looked over at me. “Fine, thank you,” she responded.
“Hey, that patient, she’s palliative,” they said. I looked at them, thumbing through the mental notes I had made about the patients signed out to me.
Ms. Calo had kind eyes—the kind that had lovingly raised two children, protecting them from the evils of the world for as long as she could. One of them sat by her side quietly and solemnly, understanding entirely well how his mother was faring and trying with every fiber of his being to stay calm so he could be there for her through her ordeal.
“The one with pneumoperitoneum?” I asked, using the medical term for ‘air in the belly.’
I sat by her bedside. “I heard the surgeons had a chance to speak with you,” I started.
“Yeah, it was a tough call because of her underlying condition, but we offered her surgery for the pneumoperitoneum and she declined. She wants to stay comfortable through the end and I agree with her decision, the risks of surgery are quite high,” he explained.
“Yes, yes,” she responded.
I sighed. Given her medical history, it made sense that she would decline the surgery, especially with the risks involved with operating on her. “Okay,” I said. “I’ll check in with her and get our internists involved.” I walked over to her room to introduce myself. “Hi there, Ms. Calo,” I said, “I’m Dr. Pavitra, I’m your previous doctor’s relief for the night. How are you feeling?” Ms. Calo looked exhausted, her skin and eyes yellowed with jaundice. Her cancer had spread everywhere — most notably to her liver, where it had wreaked havoc. The yellowing of her
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skin was from high levels of bilirubin streaming through her blood, depositing in her skin and mucous membranes.
COMMON SENSE JULY/AUGUST 2022
“And I heard that you didn’t wish to have surgery to close the hole in your digestive tract that is leaking air into your belly, is that right?” “No, I don’t want,” she responded. “Okay. If you’d like, we can get your pain under control, get you upstairs, and make sure you are comfortable then. Is that alright?” I asked. “Yes, it’s alright,” she said. Ms. Calo could only speak in discrete phrases—long conversations were taxing. I looked over at her son, who silently held his mother’s hand. “What questions can I answer about everything that is happening—I know it can be overwhelming…” I started. “Nothing,” Ms. Calo noted. Her son acknowledged her response.
After a pause, I thanked them and excused myself. Ms. Calo had already heard about her prognosis from the surgeons. I didn’t want to harp on it in what may be the final days of her life. As I got ready to reach out to the Medicine team, the nurse walked past me. “Hey, did you speak with them?” she asked. “Yeah, Surgery spoke with them too and said they wanted palliative care. She declined surgery when we spoke just now as well,” I said. The nurse looked at me quizzically. “I don’t think her son knows how serious her situation is,” she started. “What do you mean?” “I mean, he’s been saying she can be upstairs for a week to see if she will heal and then they can decide about the surgery.” “But, she’s probably not even going to make it through the week with her condition. Surgery told me she understood the risks of declining the operation…” “I don’t know, I just know that she’s still full code in the chart,” the nurse said, referring to the fact that Ms. Calo’s records still indicated that she would want ever life-saving measure taken if her health were to decline. Worried about the conversation, I confirmed with Surgery that the discussion had been comprehensive and that the patient understood the options available to her as well as the risks and benefits of each option before making a decision. They re-emphasized that the patient preferred palliative or end-of-life care. I stepped back into the patient’s room. “Ms. Calo, I’m back!” I said. She turned her head a bit to see me. “Hello!” she exclaimed back. “I just wanted to ask a couple of more questions,” I started, sitting back down on the stool near the bed. I looked at the dying woman
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