Abstract
Among the surgical team, the prognosis was universally deemed to be grim: this was not survivable. The tumor board prognosis was more guarded: he was still a candidate for palliative immunotherapy. We had been taking care of Mr. H for a long time. He was well-known to our surgical service because he had a terrible, recurrent, head and neck cancer. Despite numerous surgeries and adjuvant chemoradiation treatment, his tumor kept returning in more and more unfortunate spots in his throat and neck. In our clinic, Mr. H begged for one more surgery, something to cure him or give him more time with his beloved wife Angie and their family. We explained that there were no more surgeries left that would help him. Surgery would not cure the tumor. The silence that followed felt overwhelmingly empty, so we quickly filled it. Some people can live on immunotherapy for years, we told them.
A few weeks later, after only one immunotherapy treatment, the tumor had eaten away at Mr. H’s external carotid artery. He came to the hospital and swiftly developed massive bleeding, requiring an emergency surgical airway and several rounds of resuscitation. When his heartbeat returned, we rushed him to the operating room and dug through layers and layers of scar and prior hard work to find the hemorrhaging stump of his blood vessel in a bed of tumor. Heroically, with several hands and after several hours of work, we managed to sew the vessel closed. We had stopped the bleeding.
Through his neck, the tumor looked back at us, resolute.
The adrenaline from a rescue subsides rather quickly. Much of this is molecular, but part of it is intellectual. Our focus was no longer singular. We needed to attend to more than just the bleeding. We had to sit with Angie, celebrate this fleeting victory, and also face the tragic reality of the situation: we had no more heroism to offer.
Or did we? What does it mean to be a hero? At our weekly team conference, we discussed Mr. H’s case. Many of us searched for additional potential acts of valor. Were we sure that interventional radiology could not do something to prevent further bleeding? If he bled again, should we consider ligating his internal carotid artery at the bedside? Was it possible for him to continue the immunotherapy? A senior surgeon wondered aloud if doing nothing would cause the team moral distress. “I guess you already did everything,” he concluded. Our arsenal was empty. Defeated, we prepared to hang up our capes.
But not all acts of courage occur in the operating room, weapons drawn, bathed in blood. Courage can be vulnerability in the face of pain or grief. When Angie asked us, with tears in her eyes, if there was anything else we could do, it was hard to tell the truth. We had to fight the training we’ve had to fix and cure and instead honor the innate part of us that cares and mourns. We needed to recognize that helping families accept death while finding peace and comfort is not the same as doing nothing.
We were honest; we couldn’t stop the bleeding if it happened again. We focused on the things we were doing to ease his pain and the ways that we would help Mr. H and his family should he bleed again, one final time. As the questions petered out, silence engulfed the room, emptying it of hope. We did not waver. Eventually, warmth returned and we began to hope for other things. Angie still hoped for another try at immunotherapy but also for quality time with her husband and family. We all hoped for peace.
After a few more days, Angie decided that her husband had also done everything he could to fight the cancer and that he would now want to rest and not live any longer on machines. She had the nurses turn his bed toward the window, and after a visit from his grandchildren, he died peacefully with her by his side.
It is common teaching that gruesome heroics at the end of life are not only futile but costly and potentially harmful. Many surgical quality metrics penalize surgeons who operate within 30 days of a patient’s death. Many feel that patients with terminal illnesses should die at home on hospice and any death in the intensive care unit (ICU) is a failure. In many circumstances and for many patients, that is true. But, not always. A carotid blowout is almost universally fatal, although several temporizing measures can be employed. Do these measures reasonably achieve the patient’s goals? Is this care futile because it is palliative? How many days must the intervention buy the patient to be considered worth it? Who should have the power to decide this? How do we quantify the value of saying goodbye?
There is still a time and place for traditional, bloody heroism at the end of life, even when it is within 30 days of a patient’s death, even when a patient dies in the ICU. Angie saw us rush to his bedside. She saw how hard the ICU doctors worked to make his heart beat again. She saw how long we toiled to stop the bleeding. It’s one thing to say there’s nothing left to do and another to prove it. Neither our quiet nor our bloody heroics could save Mr. H, yet taken together, our gallant efforts enabled a peaceful death for him and some closure for his family, while solidifying our therapeutic relationship. The quiet modeling of acceptance helped guide his family on their own journey. And, our exhausting operative feat gave us the resolve to endure the empty silence with Angie and answer her questions honestly: we’ve done everything we can and we’ll be with you the rest of the way.