Written By Alvin Tng, Year Two Internal Medicine Resident, SingHealth Residency, Singapore
*All names have been changed to protect the privacy of the patient and family.
“No, I don’t want anymore chemo!”
My eyebrows raised slightly as I stood behind my Registrar who was leading the Oncology ward round. She was an attractive young lady in her late 30s, with a beautiful silk scarf tied around her head in a bandana style, concealing where her tresses used to be before the chemotherapy did its job. Her eyebrows were neatly drawn, and short of lipstick, mascara and stylish clothes, you could have almost placed her in the middle of Takashimaya, a popular downtown shopping mall, and she wouldn’t look out of place.
“I don’t want anymore chemo, and that’s final. I just want to go home!” The discussion went on for the next fifteen minutes. Serena*, was indeed unfortunate to be diagnosed with locally advanced cervical cancer, which was starting to press on both her kidney urine tubes, causing obstruction and worsening of kidney function. A different line of chemotherapy would have offered her a small chance of shrinking the tumour, but she was also well aware that the chances were slim as her cancer was very locally aggressive and so far had not responded well to previous treatment regimens. Her blood counts were just slowly recovering from the last chemotherapy, but she was hardly safe to go home with a worsening kidney problem. Options were discussed again with her – chemotherapy versus putting in a tube to release the obstruction in the kidneys and divert the urine. Neither were attractive options for the young lady in the prime of her life.
Discussions after discussions were held with Serena and her siblings. The diagrams of the kidney and the tumour were drawn and redrawn – Serena could probably draw them herself after all this time. She finally agreed to inserting a tube to divert the urine, buying her some time, but was adamant about refusing chemotherapy. The despair and pain in the eyes of her siblings and mother were ill-concealed – mixed feelings at seeing a loved one reject treatment, yet knowing that treatment itself was no guarantee of a cure.
The urine tube went in uneventfully. Serena was chaffed at having to learn how to care for the tube, but that was manageable at the thought that she could go home soon. “I want to go on a trip with my family,” she randomly let on one evening, as I walked by her bed. “Oh really?” She wanted to go on a trip with her family in her last few months – maybe Hong Kong, she mused. She was aware that refusing chemotherapy meant that she would die from her cancer eventually, but she accepted that reality. She wanted to live her last few months doing the things she wanted to do, even if it meant living her life with the shadow of death at her doorstep. Even though she declined treatment, Serena was hardly one to mope about and bemoan her poor fate.
She went home soon enough, with follow-up appointments with Palliative Medicine. Two months later, my walk-in clinic session at National Cancer Cancer Oncology was briefly interrupted by a phone call. It was from a Palliative Medicine consultant in a clinic two floors below, who rang to let me know that Serena was coming in for some symptoms. Serena? That name sounded vaguely familiar then. Fifteen minutes later, in walked that same attractive young lady with her bandana – only this time round, looking more cachexic and worn.
“How are you today?” I asked. She looked at me for a moment, before recognition lit in her eyes. “Ah it’s you again!” She was having severe symptoms of pain, nausea and vomiting, but of course, she did not want to be admitted. As my fingers hit the keyboard for a prescription, I chatted with her sister and her. She had just returned from a week long trip to Cameron Highlands with her family. As she waxed about the cool weather and strawberry picking in the highlands, the pain and furrows left her face for that brief moment. The grunt of the printer jolted her out of her reverie, as it ejected out her prescription unceremoniously. “Well, maybe I’ll get a chance to go on another trip? Thanks again for your help!” She got up, took the prescription, and walked slowly out of the room with her sister hurrying before her.
I watched the door closed behind her, as silence fell across the small consult room. Dylan Thomas’ poem “Do not go gentle into that good night” suddenly appeared in my mind.
“Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light…”
It is only human to choose life over death, but what happens when the option of life is questionable in itself? How would you choose to live out your final days?
A death sentence chained to her neck, she chose her own path. To fulfil her final wishes. To be with her family. To be truly, happy.