by Taido
In the early years of my palliative care practice, I had the privilege of meeting Madam W. She was 82 years old and had been diagnosed with terminal bile duct cancer. I was asked to see her at home for complaints of abdominal pain, apparently emanating from the cancer within and around the liver.
Madam W stayed with her son, who was also her sole care-giver. Her son introduced me as the doctor who had come to treat her pain. Madam W appeared somewhat guarded but reticent. Nevertheless, she relented to be examined. She winced as I palpated over the liver area. She had already been taking regular paracetamol (a “step 1” analgesia) and tramadol (a “step 2” analgesia).
“The pain doesn’t seem to be controlled with the current medications. I think morphine will probably help you.”
Her face started to screw up, and then she burst into tears!
As a newbie to palliative care, I was quite shocked by the response. Was I too hasty to talk about morphine? I thought ruefully.
I had started to assure her that morphine will not make her die FASTER, when her son, who seemed curiously humoured by the situation, interjected: “She doesn’t want any treatment because she is worried it will spoil her appointment. Isn’t that right Ma?”, he said.
Madam W looked at me sheepishly now, as if she was embarrassed to admit the reason for her outburst. “I have an appointment… with God”, she explained.
“She is worried doctors will make her better and she will miss the appointment, which will be in three days’ time, correct Ma?” Her son helped her with the rest of the explanation. That was also the reason why she had resisted any doctor’s visit until her pain started to be unbearable.
“Oh… but morphine is just for pain relief. It will not make you die SLOWER,” I corrected myself.
Now Madam W looked more relaxed and had stopped crying. She resumed being the placid and pleasant elderly, albeit one seemingly in smug possession of a secret.
“Show him how you have prepared for the appointment, Ma”, her son cajoled.
Madam W reached for the side of her bed and produced three pieces of A4-sized pages, on which was a long list, neatly written in pencil, in double spacing. These were her instructions on matters upon her death, such as funeral arrangements and what to do with her personal effects. She was convinced and prepared that she would surely die in three days, and one might even say, looking forward to it!
But there was a problem: she looked too well clinically to be dying in three days, barring any unexpected medical catastrophe. However, I decided it would not be a good idea to tell her that, after how she had reacted earlier.
After settling Madam W, I invited her son to continue discussing about her care in the living room. As we sat, I spied Madam W hobbling to the bathroom by herself. I explained to him that her prognosis was unlikely to be as short as she had hoped for. I suggested we start planning ahead in anticipation of her eventual functional decline and increasing nursing care needs.
The next day, I checked that her pain had responded well to the morphine. I had already planned to be on leave for a week after that and so I did not check on her subsequently. On my return from my leave, I was astonished to hear from a colleague that he had been called to her house in the wee hours of the fourth day of my visit – Madam W had died in her sleep!
I continued to think about how Madam W could have uncannily predicted her death. Was the “appointment” merely a metaphor? Did she make the “appointment” and did she receive the “appointment”? Was it an idea, or an emotional sense, or a somatic sensation? An intelligent guess or estimation? Or maybe a self-fulfilling prophecy? Of particular intrigue was how she knew even before the objective clinical parameters or signs became apparent.
Since Madam W, I have taken an interest to find out more when patients cast their own death prediction so precisely. So far, many have simply expressed it as an emergent awareness or insight about their body (“I just know”; “I can feel it”); which does not explain very much. It looks like this will remain one of the mysteries of life and death.
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
Taido is a Family Physician with an interest in end-of-life care.
