Waiting for the End

I have a very pleasant patient who is slowly dying of end-stage emphysema. He is on very high levels of oxygen and a number of medicines, but there is no cure for his condition, no remedy that he is willing to consider. He will continue to experience a slow decline until he finally succumbs and dies.

I've been caring for him for the past twelve months, when I inherited him from one of my partners. Yesterday, he came to see me again, feeling generally miserable, short of breath, and utterly fatigued. We discussed his specific symptoms, which all revolved around his incurable underlying condition. Finally, his well-meaning, relatively healthy, and somewhat frazzled wife cut to the chase.

"Doctor," she asked, "how much longer is this going to last?"

"You mean until he feels better?," I asked.

"No," he answered for her, "she means how much longer until I'm going to die." He spoke this final word with impatience.

I paused for a bit, collected my thoughts, then said as honestly and compassionately as I could, "I don't know. It is very difficult to tell in these cases." They looked at me expectantly. "Based on where you are today, I would say probably six months to a year." I waited for a response.

"Six months?" His wife gave an exasperated little half-chortle. "That's what they told us two years ago!"

We all laughed at that for a bit, at the absurdity of living a life in suffering with the sole purpose of waiting around until one day you finally die. This sort of situation invariably raises the spectre, in my mind at least, of physician assisted suicide. First of all, it's illegal. But that doesn't mean necessarily that the idea is wrong. In fact, in specific cases such as this one, it is very hard to argue against it from a medical ethics point of view. (That may come as a surprise to some, but medical ethics is full of shades of gray, and because in our western medical-legal paradigm the principal of autonomy typically trumps all others, it is hard to build an argument that would preclude a rational patient with an incurable, agonizing disease to voluntarily take their own life.)

But this encounter did not devolve into an esoteric discussion of medical ethics. Rather, this was pragmatic, a patient suffering who wanted some sort of reassurance or comfort. I felt compelled to morph into Missionary Mark, to share in a non-denominational way some of my personal religious convictions, as I will sometimes do when religous patients come to me for comfort, and medicine has nothing else to offer.

I suggested to him that God appoints our times and seasons, when we live and when we die, and that the fact that he's still alive must mean that God still has some purpose for him. I encouraged him to try and view each day as a gift and to find meaning in it, even if that was only holding his wife's hand or writing a letter to a grandchild or appreciating a flower.

Then I raised my hands to the heavens, shouted "Hallelujah!" and asked him for an alms.

Not really. But I did feel some sort of spiritual inspiration, and my patient and his wife were noticably moved.

He will still suffer physically and emotionally, will likely die within the year, and I'm under no false pretense that my one minute sermon will dramatically affect his end-of-life care. But I did have a feeling of satisfaction that, rather than offering lethal doses of morphine, I was able to offer my terminally ill patient words of comfort and perspective.