A PROMISE OF REST | Ronald Lands
I’ve been tending to a lady from my hometown. I didn’t know her when I was growing up, but she was one of my first patients when I started my practice. I’ve followed her for several years now.
Her cancer is low-grade but incurable. Until recently, it hadn’t threatened her life, but it had tortured her with miserable episodes of flushing and diarrhea. Her symptoms had been partially controlled with expensive injections. A few months ago, she developed a new pain in her abdomen because of the accumulated tumor bulk in her liver.
I admitted her to the hospital today. She was dying, but not because of the cancer. She had a blood clot where the main pulmonary artery branches into each lung. The clot straddled this fork in the road, allowing only a little blood to dribble through to be reloaded with oxygen.
She could have had a clot-buster drug or removal of the clot with a catheter, but I would have had to transfer her to a hospital with a higher level of care.
I offered it.
She declined.
I encouraged it.
She refused.
I caved.
She agreed to wear an oxygen nasal cannula, but no masks. “I’m tired,” she said as an explanation to my gentle challenge. I knew what she meant. She was tired of nausea, diarrhea, itching, pain, pain medicine, cancer medicines, being dependent, being a burden, being alone. And she was tired of wasting what little breath she had left talking about it. She was near the end and knew it.
We talked about heparin, a blood thinner given intravenously.
“What will happen if I don’t,” she said.
“Clots tend to make more clots if left untreated. Yours is in a dangerous place. You would die.”
“So, heparin just keeps the clot I have from getting worse?”
“Until your body can dissolve it.”
“How long does that take?”
“Days, weeks.”
“I don’t have the strength to go another day,” she said.
I failed to tell her that she’d need blood drawn at six-hour intervals to monitor the drug. I also forgot to talk about the bleeding risk. I don’t think I did this intentionally. I want to believe my subconscious took over and wouldn’t allow me to offer her another reason to say no.
“I’ll try it,” she said finally when the silence became almost unbearable. “But I may change my mind.”
After a few more minutes, I stood to leave. I touched her hand. She squeezed my fingers in return but didn’t open her eyes. I turned the lights off and closed the door softly behind me.
I drove home, my mind soggy with deep, dark thoughts. I found my rocking chair and stared into the darkness through my study window remembering a clinic visit when she’d told me how it frustrated her to read the newspaper obituaries every day. “Everyone brightened up every room they entered. Everyone lived lives that were vibrant, vital, selfless and so engaged.” She smiled ruefully. “That hasn’t been my experience. My dying has been long and hard.”
I hadn’t thought about the combined burdens of her tumor and the toxicity of treatment for only a glimmer of hope for a poorly defined benefit. It seemed counterintuitive, like the passage in Matthew that says, “Take my yoke upon you and I will make your burden light.”
The phone rang. It was her nurse. “She refused the blood draw for her lab.”
“That was my fault,” I said. “I forgot to warn her.”
“And she took her oxygen off and won’t put it back. She’s managed to slip the oxygen sensor off her finger. She’s insisting I take all her monitor wires off.”
I shouldn’t have been surprised. She didn’t want to do any of this. I sat in the dark, holding the phone, saying nothing.
“Doc? Are you awake?”
“Yeah, sorry, just thinking. Does she look comfortable?”
“She looks very peaceful when we’re not bothering her,” she said.
That innocent but pointed observation described exactly what I was doing. Everything I’d done was medically reasonable, but none of it would make her live longer or better. I was just bothering her.
“Shouldn’t she be on comfort care?” the nurse asked. Her voice was soft. We had worked together for a long time. I knew she didn’t want to offend me.
Of course, I thought. I should have admitted her to comfort care and avoided all the needles, monitors, pointless discussions about procedures, and higher levels of care. I was lost in a reflection about how an objective physician-patient relationship becomes untenable after sharing the weight of a chronic, incurable, illness for so many years.
“Doc?”
“Yes,” I said. “You’re right. I just couldn’t do it.”
“Sometimes it’s hard,” she said, “for us, too.”
I could think of nothing better to say.
“I’ll call you if anything changes,” she said.
“Thanks,” I said.
“I’ll take good care of her.”
“I know you will,” I said. “You already have.”
Ronald Lands a retired hematologist. He is an MFA alumnus of Queens University of Charlotte. He practiced medicine for many years in East Tennessee where he grew up. He was privileged to treat strangers, lifelong friends and a few relatives. All of his writing originates from these experiences.