Abstract
I was on the oncology unit when the alarm went off. A resident grabbed me and whispered, “C'mon, a patient is coding. You're going to want to see this!” By the time we rushed to the room, a swarm of doctors, nurses, and technicians had already descended upon the patient. One pointed at me and yelled, “You, help me with intubation!” As I maneuvered to the head of the bed, I saw the patient was one I knew: Calvin.
Thirty minutes, a few cracked ribs, and some vomit later, it was clear that the controlled chaos of chest compressions, ventilation, and defibrillation would not bring him back. An attending was confirming the death when Calvin's wife and daughter arrived. They had been in the hospital cafeteria.
This, I was sure, was not a good death.
A few weeks before, in a dim hospital room filled with intricate machines and their incessant thrums, two men laid in their beds. On the left was Ralph, a 73-year-old. On the right was Calvin, 70. Neither had a significant past medical history, yet both had been diagnosed with small cell lung cancer more than a year ago. Both were happily married; Ralph had two sons, Calvin a daughter.
Since their diagnoses, Calvin and Ralph had come to the hospital periodically but with increasing frequency. There were, of course, the usual cycles of chemotherapy. But there were also the intermittent complications—pneumonia, blood clots, bone pain, cardiac arrhythmia. Once in a while their visits would coincide and they would find themselves in the same room, co-travelers on the same wretched journey. As a medical student my official tasks involved no more than giving the occasional clinical update, but I enjoyed spending time with them, exploring Ralph's life as a nurse and Calvin's as a career military officer.
One of my last conversations with Ralph occurred shortly after I glimpsed what appeared to be a heated argument between him, his wife, and his oncologist. I waited 10 minutes after the doctor left before sidling into the room. We exchanged a few pleasantries before I asked, “I couldn't help but notice your conversation with Dr. Campbell just now. Is everything alright?”
Ralph chuckled and gestured to his wife. “Since you ask, we decided last night hospice will probably be best for me from here on out. Dr. Campbell was trying to talk us out of it. He's insisting on another round of chemo, even though the last two failed.”
I nodded, having seen this a striking number of times before, physicians reluctant to “give up” their patients to hospice. “And?” I probed.
“Let's just put it this way: I'm completely convinced more chemo isn't going to make me live longer. It'll just make whatever time I have left feel that much longer!”
Ralph was transferred to the hospice unit several floors up two days later.
Calvin, meanwhile, braced himself with the full dynamism of his military experience. It vividly reminded me of what Susan Sontag noted, in her treatise Illness as Metaphor, as the martial flavor that pervades the language of cancer. Tumors are “invasive,” “colonizing” distant organs and overwhelming the body's “defenses.” We “battle” cancer by “carpet-bombing” them. When I once asked Calvin how far he was willing to go to treat the cancer, he responded, unflinchingly, “By God, I'll win this fight or die trying.” What's darkly ironic here is that we do have the means to defeat any cancer; it's just a matter of whether the patient survives the process.
After Calvin's death, the staff soon cleaned up and left the room. Calvin's wife and daughter stood by the body, gazing at it through silent tears. I was halfway out the door when Calvin's wife murmured, “He's always been a fighter. He does things his way.”
Unsure if her words were directed at me, her daughter, or no one in particular, I turned and saw to my slight surprise, beneath her veneer of grief, an expression that could only best be described as pride. She continued, “I'm glad he faced the end staying true to himself.”
After bidding Calvin's family goodbye, I wandered up to the hospice unit, looking for Ralph. That's when a nurse informed me that he had died two nights before, in his sleep, likely from pulmonary emboli. His last day had been spent with family, reading together, and attending a poetry recitation in the hospital atrium.
In the two years since starting medical school, my experiences in the hospital have enabled me to formulate a notion of a “good death.” I certainly knew what I wanted mine to look like. Quiet. At home. With family. Preferably with soft music playing in the background. Ralph's death was a good death.
Both men had been roughly the same age. They had the same stage of the same cancer, diagnosed at the same time. They had equally supportive families and positive outlooks. They had passed away at around the same time.
But Calvin's death had been intrusive, messy, and harrowing. He had died, after protracted aggressive chemotherapy, amid a pandemonium of shouts, sirens, and piercing lights. For some time after Calvin's death, I felt greatly saddened and disgusted by how antithetical his last moments were to how I believed it could, and should, have gone. It just felt profoundly wrong.
Nonetheless, in the subsequent months, what Calvin's wife's said, reverberating like a song stuck in my head, has forced me to acknowledge the inadequacy of my convictions. Calvin never wavered in his determination to beat the cancer, and who was I to say it wasn't right? Yes, Calvin's death was a nightmare. But it was my nightmare, not his. I now know to look always for even the smallest things we can do to empower patients with the prospect to brave diseases—and death—on their own terms. Ultimately, and more so than a painless or peaceful death, this may just be the most powerful gift we can give.