8 March, 2021
A good death

Author: Dr. M. Suneetha, Radiation Oncology

Aging parents and their willfulness are matters close to the heart of every person. As a daughter I deal with the stubbornness of my parents almost everyday and as a doctor I come across this trait quite frequently among my patients who are senior citizens. Often, their own children look up to me to find a resolution to the problems posed by parents holding on to their last bit of independence. They are often reluctant to get themselves treated, particularly if they are afflicted with cancer, on the grounds that they have fulfilled their duties and responsibilities and are unwilling to suffer more to live a little longer. While going through some of my old files I came across this case of one of my patients, aged about 60 who came with a complaint of bleeding rectum which he had neglected for past two years. This retired gentleman was tall, slightly built, fair and still quite handsome and hailed from one of the richest families in the city. He came along with his wife and son who were both quite anxious about his health but at same time unable to handle his adamant attitude. He was boorish from the very beginning.” Why should I go for this treatment? I have fulfilled all my responsibilities; my son has a good job, he is married and I have grandchildren too. Maybe God has given me this disease to call me back to him,” the gentleman said. He went on,”Why do you doctors want to treat an old man like me? You can earn your money by treating someone young, not on an old person like me who already has a foot in the grave. Instead, do something to hasten my death.” It would not have been worthwhile to explain to him that euthanasia was not permitted in India. But I could explain to him the concept of “ a good death” which is defined as “free from avoidable distress and suffering for the patient, family, and caregivers, in general accord with the patient’s and family’s wishes, and reasonably consistent with clinical, cultural, and ethical standards.”

But I understood he had lost the will to live and he was convinced that doctors treat patients only for money. For somebody born before Independence, the moral corruption in every section of the society must have been frustrating but I had to look for a way to convince him to get treated. It was going to be a challenging task and would need a great deal of time. I requested him to wait a little longer so that I could finish my ward rounds and approve the radiation plans for that day. I came back to OP after an hour and he was there patiently waiting for me.

He had already consulted a surgical oncologist in another hospital. The oncologist was a close family friend and found that the disease was a locally advanced case of rectum cancer which could not be operated directly owing to its advanced nature and advised him to undergo radiation and chemotherapy first. This would shrink the tumour and make it amenable to surgery. He was referred to a radiation oncologist in the same hospital, who explained the entire treatment procedure to him but he was not convinced. Then the family had sought me out with the hope that I would be able to convince him to go for the treatment.

He had a long history of piles and managed so long with symptomatic medicines. But in the past two years episodes of bleeding had increased in frequency and of late he experienced pain during defecation. He had consulted a family physician who examined him and suspected malignancy and referred him to an oncologist immediately. Following investigations it was found to be cancer in rectum, at stage III. His frequent visits to the hospital for consultation, investigation and the endless wait for reports had made him bitter and the final diagnosis of cancer left him in a state of denial and depression.

I started by explaining to him that these investigations were required to know whether the disease had spread to any other organs. As the disease was found limited to the pelvis we had a chance of tackling the tumour with aggressive treatment. Hence, all three modalities of oncology that is radiation, chemotherapy and surgery have to be followed. In response to his words about earning money from his treatment I politely pointed out that I was employed by the A good death hospital and would be paid my salary irrespective of the fact whether he gets treated or not. And added in good measure that it was he who had come to the doctors due to his pain and sufferings and not the other way round.

I am never rude to my patients but in this case, I felt there was a need for some stern talking without being impolite. I could see my plain speaking had the desired effect and he had mellowed down a little. Therefore, in the same blunt tone I continued, “You said you have fulfilled all your responsibilities. Your only son is a project manager in a reputed company in Bengaluru. He left his family and workplace commitments to come here. Why do you think he came here?”

“I know he has come for me. I don’t want him to be torn between me and his work and other family commitments. That’s why I want to go quickly,” he added morosely.

I said, “I am more worried about your son than your wife. Why are you unable to see the pain in his eyes? Despite his busy schedule nothing could stop him from coming here. You took 60 years to finish all your responsibilities. But the rest of your life is no longer yours. Now it is up to your children to take care of you. This is the rule of nature, parents take care of their children and then it is their turn to take care of the parents. This is a cycle that began with that of humanity and applies to all of us. When my father was ill I told him the same thing – it is my right to take care of him and he cannot deny my rights. I am able to balance my work and my duties towards him. And at the end of the day it gave me immense satisfaction to be able to look after my parents, particularly when they are sick. Your son also requires that same satisfaction and you cannot deprive him of his privileges.
Otherwise, he would live with this regret for the rest of his life and never rest in peace.” As I was speaking to him I could feel there was a change in him. He was sitting straighter and I could detect a flicker of interest in his eyes.

“You unnecessarily delayed the treatments and allowed your disease to become advanced. Understand this simple truth of life that you cannot leave this world either a day earlier nor a day later. Each one of us will have to wait for our designated moment. But if you leave your disease untreated it will make your life as well as those of near and dear ones difficult. Do you want your wife to suffer that fate where you can no longer manage your toilet needs?” I said knowing fully well it will cause a great deal of consternation to someone who obviously had an independent nature.

This discussion went on for an hour and I shared tales about my previous patients and finally, he asked, “So according to you the rest of my life belongs to my son. Do you mean to say I should not have any wish of my own ?”

I replied, “You can harbor any wish except that one for death. How you want to spend your time, where you want to go, what you want to do – are all in your hands.”

“So do you guarantee that I will survive? And what about the side effects?” the gentleman asked tentatively.

“No, I cannot give you that guarantee but I will try to treat you to the best of my efforts. No treatment in this world comes without side effects but I can assure you that I will try my best to make you comfortable,” I told him.

I didn’t know whether it was my counselling or the pain of the disease which compelled him to seek treatment but finally I started radiotherapy which was slated for 28 days. Chemotherapy was also given in the form of daily tablets. He was more scared of the surgery as it would have resulted in permanent colostomy – a procedure in which a part of the large bowel is drawn over the abdominal wall and opens into a bag, so that all the fecal matter is collected in it and disposed off as and when the bag gets filled up. I told him we wouldn’t be able to avoid surgery at any cost but we could finish radiotherapy first and then go for it. His son thanked me profusely, “You spoke what was in my heart.”

The gentleman turned out to be a model patient. There was no complaints even when the radiotherapy machine broke down repeatedly and he had to wait for long hours. And in fact, he went out of his way to comfort other patients. He religiously followed the instructions of his doctors. Finally, we successfully completed the course and managed all the side effects with minimum possible suffering.

He went back to his surgical oncologist as he felt more comfortable with him. However, before leaving the hospital, he met me and said: “ Though you are younger to me, I should convey my appreciation for your matured way of thinking and I admire your parents for raising you well.” This was the best compliment I ever got from my patients and his words will forever remain in my thoughts.

Treating such patients brings utmost satisfaction as there is a lot of psychological counseling involved. Oncology is a unique branch in the field of medicine where the patient, as well as the family, require emotional guidance to traverse a difficult journey. The success of the treatment often depends upon the time a doctor spends with his patient and his caregivers. Hence, either we should cut down on the number of patients we treat or extend our duty hours and then only we can do justice to our patients.

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