By Taido
SM was a burly 72-year-old man with an imposing presence and a spacious heart to match. Unfortunately, he had been afflicted by an aggressive cancer that started from the floor of his mouth. Despite various oncologic treatments, the cancer had extended into the neck and chest, and disseminated to multiple bones, in particular, the left pelvic bones which caused him significant pain. But more harrowing was the progressive disease in the mouth and neck, which can lead to increasing difficulty in breathing as the air passages become constricted by the cancerous growth. In extremis, the condition will be intractable to any intervention and will inexorably result in death by asphyxiation. When that happens, the only grace saving measure left is to sedate the patient so that he did not need to suffer the dreadful ending.
As feared, SM was eventually admitted to the hospital with signs of worsening airway obstruction and left hip pain. But SM was not one wont to self-pity; he wanted to tackle the matter head on. According to his wishes, an urgent family meeting was convened by the bedside to discuss his management choices. His wife and all four of this children and their spouses were there. I hesitated for a while when I noticed the presence of a young child – his 9-year-old granddaughter, resting in the arms of her mother. It’s OK, declared SM, “We are quite open as a family” – that set the tone for us to begin.
It would not be an exaggeration that his self-assuredness made it easier for me to broach the discussion about such horrific endings. “Just sedate me and don’t let me suffer at the end”, he said decisively after hearing about the situation. I looked towards the family for their response. After a momentary pause, and with SM’s prodding to say what was in their hearts, his wife provided the rejoinder with tears in her eyes: “I will support any decision he makes”. And following this, each of his children individually articulated their support for him. It was an incredibly tender and moving session. And yet no one really broke down emotionally, owing I believe, to SM’s fortitude in holding that space in the face of the tragedy.
The condition worsened expectedly the next day, and he was breathing noisily and laboriously; the oxygen levels became unstable. “Sedate me now”, he pleaded with his now raspy voice. I reminded him that this might be the last time he would be conscious as most people with this condition dies within hours to short days. SM replied with the thumbs up sign!
And so SM was sedated, and the family prepared for his demise. But for some unusual reasons, his condition seemed to improve the next day and his vital signs stabilised. With each passing day, I became somewhat more restless – it is one thing to sedate an imminently dying patient with intractable symptoms, but the indications to sedate a medically stable patient are more dubious. I started to hint to the family about reversing his sedation if his condition had “stabilised”.
But on the following Monday, after about a week of very gradual decline, SM’s condition took an abrupt turn south and he started to show signs of gasping. He died while being sedated later the day.
It was not the “usual pattern” but just as we each live differently, each of us can die in our own ways, so I surmised. The family, on the other hand, seemed less fazed by the course of the events. As I spoke with his daughter-in-law after his death, it transpired that there was another story unbeknownst to me. After that family meeting, SM’s granddaughter who was present during that session picked up a conversation with grandpa. SM, in his usual openness, alluded to his departure in short days, to which the young girl replied rather innocently: “But I still have to attend school at that time.”
“Don’t worry,” SM assured the child, “Yeh Yeh (grandpa) will solve this for you (“爷爷会帮你搞定”)”.
SM died on the first day of the school holidays.
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.
