By Taido
PK was an 84-year-old man in a transitional care facility. The ward staff had been quite vexed about what to do with him. PK belonged to the tough older generation who had lived through the World War 2 in Singapore. Estranged from his family for many years, he was fiercely independent and would have continued to live alone in the community, had it not been the diabetic gangrene of the left foot, which necessitated a recent life-saving forefoot amputation. But now a new wound was festering on the right foot. He was discharged from the acute care hospital to the transitional care facility for further wound care. But this turned out to be quite a struggle: from the care team’s perspective, he was combative and had refused to let the nurses touch him, he only wanted to have things done in his way, he took medications selectively and he was verbally aggressive to the staff, including doctors (so I was warned). In addition, he was also found to have cancer of the prostate that had spread to multiple bony sites. PK had allegedly declined any oncologic treatments. Strangely, the bone pain that he had in the acute care hospital did not seem to be an issue since entering this facility; he declined morphine and chose only to take paracetamol. The care team felt he would be a hospice candidate but they needed his consent for the referral. However, with PK’s ‘firewall’, it wasn’t surprising that they could not get anywhere near that decision.
I introduced myself and asked if I can see him. Sat up in bed, PK surveyed me suspiciously from the corner of his eyes. Nonchalantly, he pointed towards the wheelchair that was by his bed. I complied and sat there. Believing that he might appreciate better pain relief, I started by enquiring about his bone pain. “Better after taking Panadol!”, he growled without looking at me. OK, maybe we don’t have to pick an issue with the morphine today!
I went on to explain rather cautiously, that with the ongoing prostate cancer, it was possible that he might find it more difficult to care for himself because of pain and weakness. Now that really got him livid!
“Exactly! The stupid doctor in the hospital cut off my leg. Why must he do that? Now I cannot walk anymore! How can I live like this? How can I go home?”, he shouted. He went on to rant about how they did not care as they just “pushed” him to the transitional care facility.
I thought about how the current care team was also intending to refer him away as well. It is so often that within the hearts of angry people, lies a deep fear. For PK, his concern was nothing less than basic survival. Yet, it would be hard to imagine that PK could have survived thus far as a lone elderly by being a pushover either. Faced with perceived threats, his conditioned reaction for survival was to fight the threat or “opponent”, even if it was the nurse or doctor.
“You know, if it is what you are looking for, it is possible to arrange for a facility to take care of you long term, even as the disease condition worsens.” I went on to explain briefly what a hospice does. “What do you think?”
“And it will be fully funded for you”, I added the ‘deal sweetener’ quickly as I suddenly remembered that he was a Medifund recipient.
That seemed to put a brake to the tirade. He stared at foot of the bed, pondering.
“Is it OK if I asked your team to apply for inpatient hospice?” I prodded.
“Em.” That was his only reply, together with a faint nod. I waited for more.
But PK started fumbling for a wound dressing set on the bedside cabinet. He mumbled something unintelligibly at first. “Time to clean my wound”, he finally said. I attempted rather reflexively to help, but clearly, he had his own ideas. “You watch!” he commanded. I descended back to my designated seat in the wheelchair and watched him clean his foot wound.
“Well?” he quizzed at the end of the task.
It was not exactly meticulous nursing care, but he did most of the steps. The foot wound, although raw, actually looked reasonably clean. “The wound looks clean… you are doing what’s needed.”
If PK was pleased, he certainly did not show it, but at least he did not seem annoyed by my reply. He raised his hand in a sweeping gesture, as if fanning away a mosquito or fly – I took it that my time was up. He had already started clearing the used dressing items, as I thanked him and returned to the nurse station to convey his decision.
Ending Notes
The modern narrative on the end of life is often crowded and even fore-grounded by a profusion of medical details — of distressing symptoms, unrelenting diseases, futility and hopelessness. But the end of life is never merely a medical event; it is a human experience that reaffirms the inescapable human condition and what it means to really live, if only we choose to turn towards it. “Ending Notes” is a series of anecdotes depicting these human experiences, from which may be aspects that moves, inspires or edifies us about life. While the stories are based on true events, the characters and background have been fictionalised, so that any resemblance to real person(s) is purely coincidental and perhaps reflect how we can as easily identify with the human conditions portrayed.
Taido is a family physician with an interest in end-of-life care.
