thanatos

     That case before?  Yup, it was cancer.  Started out as colon cancer, went into remission, but then she developed Stave IV ovarian cancer.  Turns out her family had a condition running through the gene pool called Lynch Syndrome (or hereditary nonpolyposis colorectal cancer if you really like medicalese).  They get colon cancer along with endometrial or ovarian cancer.  And to be honest, it wasn't that emotionally hard reading all the medical stuff.  It wasn't even that hard to role play giving the bad news.  I've done that with my both my brother's and dad's diseases.  It kinda loses its punch when it's just an academic exercise. 
     But at the end of the case, we all piled into our lecture hall to watch a video interview.  A different patient at MD Anderson who had Stage IV ovarian cancer (translation - terminal) agreed to be interviewed about end of life issues.  It was less than 15 minutes and I counted the number of times I had to physically bite down on my tongue to keep tears from spilling.  So many of the same struggles and issues that were thrown at my dad and brother.  It took three times chomping down on my tongue to create physical pain out of emotional pain.  Then a rather well esteemed chaplain and rabbi at the medical center got up to tell some stories about end of life.  And through them all, he's encouraging us to drop the notion that because there's nothing medically, meaning curatively, that can be done for patients, we still have a role to play.  And perhaps it's a role that only a doctor can play.  Our relationship with the patient is unlike any other.  And if we judge our success solely by restoration of health or not, we're going to be sorely disappointed, not mention at a high risk for burnout.  But if we treat to validate and heal the patient's spirit, that's a different measure of success.  And I'm listening to all his stories about redemption and hope and peace in the face of death and I'm struck at how that wasn't there for my brother, at least from where I sat.  It was a nasty and brutish and above all, painful death.  So if I measure success by peace or healing of the spirit, did I fail him?
     And so, too, did the doctor fail him in that regard?  We all tried to move my brother towards acceptance but there is something about the aura of a doctor.  Their word carries a different weight than a family member.  But I remembered back to a line the doc said to my brother that rings in my head clearly, "so what I'm hearing you say, is that you'd rather go down swinging."  I can picture the doctor saying it, hear his voice, and see his body language like it's on a screen before my eyes.  And my brother nodded his head 'yes'. 
     We're taught to respect the patient's autonomy.  They have the right of self determination that trumps most anything.  But as a physician, at what point are we feeding the patient's mistaken belief of a cure?  There was nothing medically that supported the last couple of treatments my brother engaged in.  And from the doctor's point of view, I guess he thought that it was more important that my brother die fighting as he wished.  There was absolutely no doubt that's what my brother chose.  I don't know that's what he really wanted.  But I don't want to second guess my brother or sit in judgement of his life.  Far from it. 
     I'm torn as to what I'll do when put into that situation.  I can't see myself encouraging someone on when there is no hope medically.  But can I see myself encouraging them to heal their relationships, to do what final things that truly matter, and to heal their soul while there is still time, when they still wish to fight against any hope?  At what point is the specter of the Grim Reaper of Death really the Angel of Mercy?  And did I really go into medicine so that at times I could be the Angel of Death?