“Dad, may mga nakita sa MRI ng utak nyo na mga kumalat na puti puting bilog ( showing him the Cranial MRI with gadolinium contrast scan plates). Hinala po namin ito yong mga cancer cells sa lungs nyo, umabot na po sya dito. Kaya pala nanghihina talaga ang katawan nyo”. About a prolonged silence, my dad asked me, “Gaano pa ako tatagal? Aabot pa ba kaya ako sa birthday ko?” . “Hindi ko po masagot yan dad, baka with radiotherapy….” Then I just stopped….
I am the youngest in a brood of three, my eldest brother being a surgeon and me, an internist. But during the last few months of my dad’s life ( who was diagnosed with stage 3b lung cancer 2 years before his death and who underwent a series of chemotherapy sessions), I was the one living close to our parents’ home and constantly supervising their immediate needs. I could still feel the awkward and sad feeling of breaking the bad news of the disease recurrence to dad and mom. When the recurrence was discovered, it was already in his brain after two years of remission. And yes as the internist and private physician of our dad, I was the one who pronounced him dead a few months after this revelation.
The problem with being an internist (as compared to surgeons, OB gynecologists, pediatricians, and more so dermatologists and radiologists) is that most of the morbidities and mortalities fall under the group of patients that we handle. So after a decade or so of private practice, we had our share of patients who die while under our care and the list gets long, we become more or less used to telling bad news to patients and their relatives. From someone who gets really so down with your first dying private patient, the regularity of the experience make our soul callous (to put it bluntly) that when another of patients dies next time, we just formally seek scientific reasons why he or she suffered that fate and we keep our emotions out of the picture. We could call this our way of physician self preservation.
There are several situations when we take on a controversial and uncomfortable stance when dealing with our ailing patients. Among the things I could think of are the following:
A. Telling your patient’s relatives that he/she has a terminal illness.
B. Telling this thing to the patient.
C. Bringing in options to the relatives (difficult choices which include DNR), when the certainty of the patient improving and getting well is very slim.
D. Stopping any resuscitative or life prolonging efforts and pronouncing the patient dead.
Based on what we know as physicians, those diagnosed with stage 4 (disseminated cancer), end stage renal disease, NYHA class 4 heart failure, non resectable brain space occupying tumors, huge cerebellar or cerebral bleed with herniation, among many other conditions are patients who most likely will perish within the next 6 months.
I recall about more than 10 instances wherein I would suspect a patient with a malignancy after examining the patient (mostly elderly ones) for the first time and I would request an imaging study. In about a day or two, it would be the loved one of the patient alone who would be showing the results to me. When I did confirm my suspicion and discussed the not so good result to them, they would strongly request me ahead not to tell the patient about the bad news before they bring the patient to me the following day. The main reason they give me is that they believe he/ she will be very depressed and will die earlier just knowing about the bad news.
I strongly believe in the maxim “the patient has the absolute right to know the truth.. It is his/ her body after all. I believe it to be strongly unfair not letting him/ her know what is actually happening to his/ her body.”
But there were indeed some instances wherein the patient’s spouse or son/ daughter know much more about the patient’s mental state and emotional capacity to handle the truth. I once told an elderly patient about his lung mass even after having been forewarned by his spouse not to tell him the truth. I broke it up slowly to him by even showing him the plates and offering the option for referral to an oncologist. The patient suddenly exploded in curses in front of me and walked out with his loved ones following suit. I felt so bad then though I pressed on the thought that the patient is certainly just in a state of denial. Two month after, I heard from his neighbor patient of mine that their family went home to their province and consulted their local herbalists. From what this neighbor knows, the patient already died not seeking professional medical help. I should have asked this patient if he or she wants to know the truth in the first place even if it was not good.
I recall one situation wherein I had a COPD patient with cardiogenic shock on inotropics who eventually got pneumonia on the 3rd day in the ICU and had to be put on a ventilator. Despite all efforts to improve his cardiac and pulmonary status, the patient could not be weaned from both the inotropics and the ventilator even after two weeks, and he remained drowsy. It was pretty obvious that his relatives are having a hard time financially securing the medicines on time (patient was already on cash basis with the hospital), they could not give a go for the advice to do tracheostomy. One time, I had to call them and discuss with them the patient’s status, all the efforts we had been doing and his lack of progress, his prognosis (given an EF on 2d echo of only 21%), and how uncertainly long he would have to stay in the ICU with the present aggressive stance and the absence of assurance of his recovery. Seeing his relatives almost succumb everyday trying to secure very medications and their hopeless facial expressions, I reiterated that he has a poor prognosis and opened up the possibility of having the patient out to a private room (so he could be with his loved ones in his final hours and to help allay expenses). But they will have to sign a DNR form as the very decision means they relinquish their aggressive stance on the management. Before they signed, they asked me how many days the patient will last outside especially if it comes to a point when they had to discontinue all his medications. I discouraged them of the action but nonetheless told them, he might expire within 24 hours of doing so. Eventually the relatives signed the DNR, had the patient transferred to a private room with them, and owing to their financial constraints, even discontinued his meds 3 days after he was in the private room.
Two months after this event, this very same patient was following up with me in my clinic alive and kicking! Of course, he has activity precautions and an escort relative on the side always but this tells us that miracles do happen. If it is not yet the time for someone to go, it will not be.
Another phase of this God action of a doctor ruling over a patient’s life is when he/ she is called upon to handle an ongoing cardiopulmonary resuscitation case. On this alone there is a wide spectrum for us to decide what a patient’s chances of surviving would be and how aggressive we should become in handling the ACLS process. On one hand, there would be these patients who are very sick to start with, had been in and out of the hospital, and those who really could go into an arrest anytime. Let us call this Spectrum A. On the other end of the spectrum, there may be this very active young person who suddenly falls and goes into an arrest. Let this set of patients be called Spectrum Z.
I remember having read in the Washington Manual of Medical Therapeutics that if one does the ACLS sequence and protocols, he / she is advised to call off the resuscitation efforts after 15 minutes if the patient remains in asystole. The rationale for such is beyond 15 minutes of no brain circulation, the patient is assumed to have sustained irreversible brain damage.
The reality is this principle may be applicable if your arrested patient is within spectrum A. But for those within spectrum Z? I recall an ACLS done on a husband of a middle aged colleague of mine who was suddenly rushed to a hospital after losing consciousness while jogging. The patient was fond of joining marathons before. It took the attending MD an hour and 30 minutes of active resuscitation and ACLS before he pronounced the patient dead.
As for me, there was an instance wherein I was handling a comatose patient with a huge inoperable intracranial bleed who had been status quo for 4 days in the ICU. I had divulged the poor prognosis to her relatives and opened up DNR as an option. However, they refused as I was told the patient still has a daughter coming home from the US en route. The patient even went into arrest the day after, ACLS still conducted with strict instructions from the relatives to be aggressive ( rhythm achieved after 20 minutes). The patient’s daughter arrived the evening of the arrest and visited her mother. Two hours after, the decision for DNR was made. The patient expired 30 minutes after the relatives signed. She was 78 years old.
This goes to say that it is not just the age and medical condition of the patient that dictates how aggressive you should be in conducting a resuscitation but also the family’s values. I even recall an ER resident physician telling me how he was roughly chided by a patient’s relative when he pronounced someone dead (DOA) after about 30 minutes of ACLS. “Hindi mo man ginawa lahat. Hindi mo sya binigyan ng electric shock!”. Apparently, the patient has asystole and at best, an unsustained idioventricular rhythm in between, so there is clearly no indication to do a cardioversion nor defibrillation. However, this is pretty hard to explain to a desperate angry and frustrated relative.
It is my routine to call on the deciding and responsible relatives when their patient’s prognosis is not good. When asked what his / her chances of surviving are, I now always add the phrase “Based on medical statistics and my limited experience, going on with our management there is about only this ____ % of survival and if ever he would survive, this will be our expectations…” One of my consultant mentors told me this on my first years of practice. He told me to speak with conviction whenever divulging unpleasant news. Back it all up with all the medical interventions you did to help the patient and the rationale of each intervention. Your endpoint is to impress upon your patient and his / her relatives that you (or your team) did your very best.
Yes, we may be God’s instruments of healing but we are not Him. God is the Author of life, never should we use our knowledge to actively end it. While we may be regarded as His stewards for promoting health and prolonging life, it will still be God’s will in the end that will prevail. Somehow, I believe part of our role is to help our patient and their relatives believe in this too.
- Raymundo Marquez Jr. MD
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