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01/09/2018

“You Had To Be There …” Caring for a Patient to the End of Her Life

By David C. Leach

It has been more than thirty years since she first came to see me – a vital woman in her early seventies who had detected a lump in her breast on a self-exam. A diagnostic work up confirmed cancer and the smallish lesion was removed. It never recurred. By the time a second lump appeared in the other breast we had come to know each other. She was now in her late seventies and this lump also proved to be cancer. It was removed. Postoperatively in the hospital she looked a bit depressed.

She was not an alcoholic, however, she had told me that she enjoyed an occasional martini before dinner. I did something I had never done before and have never done since. I brought a Waterford crystal glass containing a nicely mixed martini to her hospital room. She accepted it without comment. We talked while she sipped. She told me that she had discovered and joined the Hemlock Society. In her words: “Dr. Leach, I know that given your lily white ethics you would never countenance euthanasia so I joined the Hemlock Society. I now know what to do and you needn’t trouble yourself.” I thanked her for her consideration and we talked briefly about her concerns and choices. In my opinion she was not at risk for suicide. She knew that this lesion also was small and with negative nodes would likely not recur. What she wanted was to be empowered to make her own life decisions. I assured her that she was. . .

She also wanted another martini. “Did you bring another?”, she said shaking her glass. “No”, I replied, “I did not bring another, you know, it’s not customary to bring martinis into the hospital.” She developed a twinkle in her eye and said: “Martinis are a lot like breasts, one is not enough and three is too many.” We both laughed.

I continued to follow her and she did well. About a year later she told me that she had renewed her membership in the Hemlock Society. I responded that if there ever was an organization that you should not have to renew your membership in it would be the Hemlock Society. After all if you took their advice it would be a moot point. We both laughed.

A few years later she called me from Arizona. Now in her mid eighties, she noted that her urine had suddenly turned orange and that the whites of her eyes were yellow. She had no pain. My heart sunk. Painless jaundice in an eighty-six year old is never good news. I told her of several good hospitals in Arizona, but she wanted to fly home right away. I saw her the next morning. A few tests confirmed our worst fears – she had cancer of the head of the pancreas. Options were reviewed and she chose surgery. She wanted to live. A Whipple procedure was performed and she tolerated it remarkably well. Postoperatively she wanted to explore all avenues of treatment. She had chemotherapy and traveled to New Jersey to enroll in a protocol involving monoclonal antibodies directed against her particular cancer – a new technique for the time, and one that in her case proved ineffective.

The next several months witnessed her inexorable decline. She wasted away and was essentially bedridden in her home. She opted for home hospice and I continued to see her in her home two or three times a week. At one visit she said: “You know, Dr. Leach, you told me once that if I had any pain you would get me something for it. As it turns out, I have not had any pain, but I wonder if I could try whatever you were going to give me anyway.” I said yes and gave her 10 mg. of liquid morphine under her tongue. After a while she said: “Oh my, this is wonderful, why didn’t you tell me about this before?”

I explained that she could take it for anxiety as well as for any pain that might develop and explained the dosing. I told her that I would leave the bottle at her bedside. I also told her that if she took the whole bottle all at once it would kill her. The hospice nurse was to track the use of morphine, but would leave the bottle at the patient’s bedside and at the patient’s discretion.

One evening two weeks later, I was called and informed that my patient had died. I went to her home to pronounce her. The bottle was still at her bedside and had been untouched. The hospice nurse confirmed that the patient had never taken even a second dose.

Did I do the right thing? How about if the bottle had been empty? I think I did the right thing and I would be comfortable with my decision even if the bottle had been empty. However, I can understand that others may have a different opinion. To them I would reply: “You had to be there.”

 

David C. Leach, MD, was trained and practiced as an endocrinologist.  He served as the Executive Director of the Accreditation Council for Graduate Medical Education (ACGME) from 1997 – 2007. He is a member of the Board of Trustees of Mercy Health.

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