When letting go is the hardest thing to do
This is the first in a series of pieces The Punch will run featuring speakers from the upcoming Adelaide Festival of Ideas. This week, oncologist Ranjana Srivastava writes about the last days of a terminally-ill patient.
Surprisingly, it takes until mid-morning for the code blue call. The way he has declined, I would have expected him to have breathed his last by now.
Aghast at the code, I climb the stairs two at a time to get to Mr Johnson’s bed side. There he lies, surrounded by a throng of doctors, each moving to a different part of his body, to bring it back to life.
“Quick, is he breathing?” asks one. “The pulse, the pulse”, presses another, already plucking open the patient’s gown. “Mr. Johnson, wake up, wake up darling,” urges his lovely, white-haired nurse.
I break into a cold sweat, instinctively detesting the unfolding scene. Mr. Johnson is nearly naked, a doctor at every limb and then some more. A thin sheet barely covers his modesty but the rest of him is there – pale, wasted, jaundiced. A once tall and proud body ravaged by cancer.
“Who knows this guy?” someone shouts. “Who has a history?”
Sidestepping people and machines, I get to the front. “I am his oncologist. I don’t think we should resuscitate him.”
The eager, young doctor poised to intubate him halts, but someone else interrupts now.
“But there is no NFR (not for resuscitation) order.”
Suppressing a groan, I say quietly, “He is terminally ill. Let him go.”
Someone else pipes up. “The son from Sydney is on the line, he wants everything done.”
“Wait,” I counsel. “I have never seen his son involved before. I don’t think he knows much about this.”
I could just be talking to myself, for in the next minute, the doctor at the head of the bed has connected Mr. Johnson to the ventilator. The monitor depicts a reluctant pulse. Wheeling him out, the doctor says blithely, “I guess we can always pull out if the family wants.”
With growing regret, I watch Mr. Johnson’s helpless figure swallowed by the elevator. He is gone. To the intensive care unit.
The CEO son and the lawyer daughter arrive that evening. In the nine months that I have known Mr. Johnson, I have never once met either. They look inconvenienced to have had to dash to hospital.
“What are his chances?” they ask. Are they optimistic or naive?
“He is seriously ill. The cancer has spread to every major organ,” I respond.
“But you can treat this.” Is it a statement or a question? I treat it as the latter.
“It is unlikely that he will improve, I am sorry.”
“But we have to try, Dad is a fighter.”
I want to tell them that he stopped fighting when his beloved wife and their mother died three months ago from a massive stroke. For the first time, he wept openly in my office, rueing the loss. “I am 85 years old, my dear,” he said. “This is not fair and I pray that my time comes soon.”
At the next visit, I urged him to put his wishes in writing. “Who would want to keep an old man like me alive?” he had laughed. “When my time comes, just let me go. It’s been a blessed life.”
In the silence, I study his children’s expression. They are clearly stunned and grasping to come to terms with events. Mr. Johnson had spoken proudly of their achievements but also regretted their gradual distancing. “The more famous they become, the less time they have for us old folk,” he once said.
“You know,” I say gently, “your father has had a difficult few months. He just wanted to go in peace.” I hope that they will hear his plea through my lips.
The daughter swallows her tears then wipes her eyes roughly.
“I could never let my father die.”
I breathe deeply, and unbelievingly. He is dying, I want to say. You are simply standing in his way to dying comfortably.
I know that I have lost the battle for Mr. Johnson, but I turn to his son. The struggle on his face is apparent. He has one hand on his father’s bony arm, bruised and bandaged after several attempts at inserting an IV. With the other hand, he crushes the handkerchief in his lap.
“I don’t know,” he finally sighs. Part of my wants to let go, but another part says he is my only parent. He goes, and that’s it.”
I feel crushed by the weight of their selfishness. I steal a look at the intensive care doctor sitting next to me – he looks the way I feel.
Between us, we try some more. We tell the son and daughter that they need not bear the burden of withdrawing care, but permit us to do what is in their father’s best interest. We tell them that intensive care will merely prolong their father’s inevitable demise. But we know that there will be no consensus.
So it is that Mr. Johnson spends the next three days in the ICU. I feel a stab of guilt each time I see him. I remember him dignified and gracious at diagnosis, courageous in battle, but realistic in expectation. As I survey his tired face and broken body, I regret his needless suffering at the end of life. If only he had put his wishes in writing and not left others to reflect his own practical sentiments when he was infirm.
I feel sorry for his children, caught up in a tragedy that they apparently never saw coming. And I understand that while I, as a doctor, may have become adept at separating hope from fantasy, they are not. Perhaps what I see as their selfishness is their understanding of duty.
Mr. Johnson dies in the intensive care unit six days later. I am immeasurably relieved. So in fact are his children.
“We did our best,” they almost plead. “We did, didn’t we?”
I think of Mr. Johnson. I think of what this most generous and courteous of men would want me to say to his children. He would tell me that sometimes we all just need to let go. Of our deeply held ideas, cherished beliefs and sternest convictions. Of blame and counter-blame.
“You did. Your father loved you very much,” I say as we all walk out.
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