Abstract
Her family gathered around as I walked in the room, hovering, holding her hand and trying to comfort her, helpless as she gulped for oxygen blowing through the mask, puffing it out, grunting with each breath, and then gulping to get some more in. Although she struggled to breathe, she was awake, and nodded to me, her eyes revealing large pools of black, highlighted by vivid shiny chartreuse reflecting the fluorescent lights from above. They were striking, unlike any eyes I had seen on any other human being, gleaming at me from beneath a set of high arched eyebrows that looked surprised and bright, even as she lay dying.
I was taken back to that day in my childhood when I caught a sunfish, colorful and glistening as she flopped around at the end of my line, struggling to escape, her green eyes vividly shining as they reflected the sun. I watched my grandfather rip the hook from her mouth and drop her on the dock, her sparkling, sleek body gulping helplessly for water that was not there, fanning her gills with her entire body, until finally the gills stopped flapping, and the shiny eyes lost their life. My grandfather congratulated me on the catch. I wanted to pick her up and throw her back in the water.
This consult was more urgent than most. Julia needed a tracheotomy or her life could end at any moment. She was awake and alert, despite the pulse oximetry monitor that struggled to stay in the 80s, and was able to understand the information the doctors were telling her; she understood the urgency of the surgery, and she said “no.” Julia looked over the mask as I said hello. She nodded when I asked if I could speak with her family and let her rest, then I ordered a dose of morphine, and she lay back against her pillow.
The surgeon pulled me in to the hallway. “I have no idea how she's moving air! There's no visible airway on exam, and her scans show a complete blockage. She really needs that trach now, or she's going to suffocate to death right in front of us, and that will be an awful way for her to die. I think we could make it much more comfortable for her if she'd change her mind.”
“Yes, she looks like she's close. She's pretty clear about not having another surgery though,” I said, as I glanced over the surgeon's shoulder to see Julia falling asleep, wondering if she was getting more comfortable, getting closer to dying, or both.
The surgeon went on, “She has been refusing surgery since we admitted her last night. These tumors often invade the large blood vessels, and cause a stroke, which may ultimately be better than suffocating to death. Whatever you can do is appreciated.”
I went back in to the room and talked to her family and friends as she rested. Despite the way she looked, they were all in agreement; Julia did not want any more surgery and had been consistent in this message for weeks. She knew she was at the end of her life. All she wanted was to go home, if we could make it happen. I knew that making her comfortable would be challenging; getting her home seemed out of reach. I wrote orders for some steroids and pain medications. After spending some time with my new patient, I left hoping that I had done some good, and wondering what I would find when I checked on her again.
I returned 12 hours later to a different person. Julia was awake and resting comfortably. The mask was off, and her oxygen flowed through the thin tubing on her nose. She wasn't able to talk, but her eyes were bright, and she smiled and nodded as she mouthed the words “thank you” when I greeted her. I envisioned her as the woman she was before she was “a woman with cancer,” with bright expressive eyes full of life and determination, and a warm welcoming smile.
She continued to improve over the next few days, and was able to talk a little and laugh by the day she was discharged. She told of her struggle with her cancer and her resolve to fight, and how in the past month she accepted that there was nothing more she could do. She felt lucky to be going home, rather than to die in the hospital. I knew the effects of the steroids were only temporary, but she did not want to talk about specifics, so we never discussed what might happen in her final hours. She giggled and her eyes flickered with life as she left the hospital. I felt a lump in my throat knowing I would never see her again.
She was in my thoughts frequently in the following weeks, remembering her desperation and her panic-stricken eyes the day we met, and her contentment as she left the hospital. I prayed for her final days to be easy, and hoped that she would have a stroke, simultaneously reflecting on how distorted my wishes for good outcomes had become as a palliative care specialist. I watched the obituaries for the days and weeks that followed looking for the expected tribute to the woman who had “lost a courageous battle with cancer,” wondering if anyone's obituary ever described a cowardly battle with cancer.
Mostly, though, I thought of Julia's eyes, and how they reminded me of my fish on the dock that day long ago, wishing I had plucked her up off the painted boards and thrown her back in, even as she died. The little sunfish had battled courageously against the line, endured the indignity of the hook being ripped from her mouth, and had spent her final minutes alone on the dock, gasping, working, gulping. … waiting. There was no choice but to fight in the battle; it was simply a reflex. The courage came in the acceptance of her fate, waiting alone on the dock, knowing that life would end soon.