Working in the emergency room is sometimes like dancing with life on the edge of a precipice.
Our work is hard. We deal with the suffering, the pain, the cries and the tears every day. But this work is also full of rewards. It gives us an uncommon resilience and an understanding of life.
I like to share my stories with you. I like to share this understanding that life is fragile and we must tend to it’s every instant, we must appreciate the moments we are given, the good and the bad.
Last week i was meeting a woman with lung cancer. Entering the room, i immediately noticed her breathing was labored. I shook her hand and i presented myself to the family members. I sat down and i took her hand in mine. I looked in her eyes and asked simply:
– What can i do for you today?
This simple question is at the core of my practice. I have left the common paternalistic “i am the doctor, you are patient” relationship a long time ago. I try to be close to my patients “I am Doctor Pham-Dinh but please call me Martin, how can i help?” I am there to help, give advice, guide. I am not there to decide and direct.
Her answer was simple:
– Can you give me new lungs?
– Let me check… I take my phone out and i answer: Sorry, Amazon does not have new lungs in stock today.
…She smiles. The tension in the room disappears. We laugh together.
– Seriously, what can we do today to help you?
– I am short of breath.
– Since when?
On and on, the discussion continues. I explain that if we are lucky, the shortness of breath is caused by an infection that could be treated with antibiotics but really, it is most likely her cancer that has grown because she now has lumps on her neck that i feel are metastatic lymph nodes.
– Has someone told you or do you have any idea how long you can expect to live with this disease?
– No.
– Would you like to know?
– Yes.
– I am not a specialist but let’s work this out together…
– OK
– When was the last time you felt 100%, like you had no limitation, like you could do anything you wanted?
– One year ago.
– And today, how do you feel?
– Well, i can’t breathe, i can’t get out of bed on my own so i would say 25%.
– OK, let’s see… 100% last year, 25% now. That’s -75% in 12 months… that is -25% every 3 months.
– Ohhhh….Ouchh..
– How do you feel about this.
– I kind of knew but i did not want to see… Thank you.
– Now have you decided about end of life care?
– What to you mean?
– Do you want to get active resuscitation manoeuvres?
– What to you mean?
– If your breathing becomes more labored, do you want to be put on a respirator? A machine that breathes for you? It comes down to the important question: how much suffering are you willing to trade to buy more time? Modern medicine can hurt you to keep you alive, put a tube down your throat and force you to breath when your body wants to stop. We can put tubes in your chest to drain cancer fluid. You can buy a little time… but not much and you will get a lot of pain in return. Honestly the vast majority of cancer patients don’t want that.
– OK, i don’t want that.
– What do you want?
– To breathe.
– Let’s do a few test and see what is causing this labored breathing.
A few hours later i come back with test results.
– Unfortunately, i must tell you that your breathing problems are caused by the progression of your lung cancer.
– OK.
– Now, we must decide together what to do and I have to options for you. I can have you see an oncologist. We can see if draning the fluid with a chest tube will help. They can try another cycle of palliative chemotherapy. But again, you will trade pain for a little bit of time. You know that cancer does? It grows, it never stops growing. You’ve fought this for a year and you can feel it. As it grows, it will hurt you more. Considering this, the alternative option is palliative care. The palliative care doctor’s concern is to make your life as comfortable as possible so you can enjoy the time that you have left. Patients accept palliative care when they are ready to stop fighting.
– I want palliative care, please.
– OK. We’ll do that.
– One more question doctor… Do you really think i have 3 months to live?
– Honestly no. You are short of breath, you can stand up, you are very weak… We might have a month or so.
– Thank you for your honesty.
Off i go to write admission orders, palliative care consult and prescriptions to make her more comfortable. I leave her with her family. They will cry together and face what life brings together.
In the end, life is not about the things we have, it is about the people, it is about the love we give.
Original post Facebook, October 2017
Martin Pham Dinh 