Some years ago, my sister had lung cancer that had spread widely, after it was diagnosed two years prior. With chemotherapy and radiation, she lived beyond the expected six months, actively serving in church, despite much pain and a limp.
She became increasingly breathless and asked to be taken to the oncology palliative unit. I think she knew it was her last day. She asked if she continued with oxygen whether it would only delay the inevitable. I told her “Yes”. It was very hard to see her struggle with so much breathlessness, yet pushing away the oxygen mask.
We said sorry for our past neglects and mistakes. We told her it was okay for her to go and promised to take care of everything.
There was an initial struggle and fear that slowly gave way to a kind of peaceful wonder. Her final words were “Come in. Come in”, as if she was welcoming familiar friends. I asked her, “Who are you talking to?”. But she had left.
It was so peaceful. I knew she had just stepped out and entered another phase of life — a new place where all is well and alive in the memories of the people she had deeply touched.
I call the process of dying a birthing into the other world. Like birth, it is messy, painful, and uncertain, until it is completed.
Can we allow loved ones to stay and keep watch with the dying, instead of all the heroics of CPR and the terrible indignity of dying, alone, among cold strangers, with broken bones and tubes?
Rather than ventilating a patient to a flat ECG or flat brain wave, perhaps we should extubate (remove the ventilator tubing in airway) earlier, hopefully while the patient can still talk.
The dying person might need to say things which he had never said before to the ones closest to him, loved or unloved. This might help the grieving process of those left behind.
Perhaps it is time for all hospitals to have rooms specifically set aside for the dying patient to be surrounded, not by medical staff, but by family members and loved ones.
The privacy, instead of flimsy curtains in crowded wards, could allow free expressions of grief, reconciliation, or regrets. This may serve as healing and closure, even when we do not really know if the dying can still hear or feel anything. At least the living will be given a chance to say “I’m sorry” or “I forgive you” before death, and vice versa.
Medical education has to include dying, palliative care. and the ethics and cost implications of managing terminal or dying patients. DNR (Do not resuscitate) should not be just a patient’s decision or living will.
The medical team managing the case may be too emotionally involved to make the decision when the patient collapses, but perhaps should discuss DNR with the patient’s relatives much earlier.
Such decisions are difficult to communicate to grieving or angry relatives who may insist on continuation of all measures, despite the zero prognosis.
In government settings, where relatives do not have to pay, this often results in ICU beds being full of patients who are really dying. Acute cases (with good prognosis) needing ICU beds are often forced to be ventilated in the wards, with sadly poorer outcome than in ICU settings.
I often wonder — when we ventilate or resuscitate someone till death (and sometimes impoverish the family in the process), whether we doctors know when, or how, to let die?
Are we saving life or merely delaying death? At what cost, and whose cost?
Dr Tan Poh Tin is a paediatrician and public health specialist.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.