04 October 2004

--- How Will You Know When?

It began with a headache.

A 77-year old man was taken by his family to a nearby lying-in medical clinic for consult. A young doctor saw the patient, took his blood pressure, got a 120-over-80 reading, prescribed mefenamic acid, 500mg to be taken every 8 hours after meals, and sent the old man back home to rest.

Around 9 hours later, the same man is in the emergency room of a big hospital in the south part of the metropolis. This time, in addition to the headache, there was notable weakness of the right part of the body, slurring of speech, and drooling of saliva on one side of the mouth. Blood pressure taken was 250/170, heart rate was 112, and patient was having shortness of breath. CT scan done showed a stroke on the left part of the brain. ECG showed myocardial infarction in the anterior part of the heart. Chest X-ray showed an enlarged heart with significant fluid accumulation on both lungs. Anti-coagulant medication, anti-hypertensives, and heart stabilizers were started intravenously, necessary referrals were made, and the patient was transferred immediately to the intensive care unit (ICU) for close monitoring.

After 2 days, patient became stable, still with neurologic deficits, and occasional episodes of high blood pressure. He was also adamantly requesting that he be discharged from the hospital (through gestures and movements) so he can go home to the province. For a while, his family and relatives tried dissuading him, but when they saw tears flowing from his eyes, they decided to agree with him. They then requested the patient's doctor to discharge him from the hospital. The medical resident dials the attending physician's number and tried to reach him.

The attending physician was at home, preparing for an important meeting with friends he will see for the very first time. His mobile phone rings, he sees the medical resident's number, and felt uneasy.

"What! Are they nuts? Don't they know the patient is still in a very delicate condition? He can't be discharged," said the surprised physician.

"I already told them that, Doctor. But they said they were willing to sign a waiver just so they can be allowed to take the patient home in the province," said the worried medical resident.

"What province? Let me talk to the family members," requested the attending doctor.

He talks with the patient's family members and gets the similar answers he got from the medical resident. The relatives want to take home the patient.

"And where is home? Where is this province?"

"Dagupan City, Doctor. That is Papa's hometown. He personally requested that he wants to die there," answered the eldest son of the patient.

"Nobody's going to die if he remains confined in the hospital," insisted the doctor. "Do you know he could die while on his way there? And do you know how far Dagupan City is from Manila?" asked the now-frantic doctor.

"We understand, Doctor. We are willing to sign a waiver. That is what Papa wants. That is the least we can give him for all the good things he had done to us," said the son. The doctor can hear muffled weeping in the background.

"Also," continued the son who spoke heavily but sternly, "we will appreciate it if you can accompany us to Dagupan City. You are the only doctor he trusts and he has been under your care all these years. Can you watch over him, Doctor? We personally request it, if you don't mind," requested the son.

"S**t! This Friday is going to be messy," thought the doctor.

The attending doctor declined to answer, and decided to go to the hospital instead. He calls his friends and apologizes that he cannot meet them because of the recent development.

Once in the hospital, he tried to talk the relatives out of their decision again but to no avail. He entered the room of the patient and saw that he was indeed crying. He was also mumbling an almost inaudible "Aupan, Aupan," which the son loosely translated as "Dagupan."

To cut the story short, the patient was discharged that evening and the family members hired an ambulance to take them to Dagupan City. The worried doctor was with them. When they reached San Carlos in Pangasinan, the patient had a cardiac arrest and expired. No attempts to resuscitate were done because of a previous signed family request.

The doctor in this story is me. This was what happened to me last Friday evening, and this was the reason why I failed to meet BatJay, Sassy and Tito Rolly.

I came back to Manila Saturday evening, drained, weary, exhausted, and sad. I fell like a log to my bed and fell asleep with my head full of questions that until now I can't answer. Maybe you can help me out:
  • Did this patient have a death wish?

  • Why do elderly men (and women) with chronic illnesses seem to have this "urge of going home" when they feel that their time is near?

  • What is "dignity in death" and how can one recognize it?

Many of you will probably say that had the patient decided to stay, he would still be alive today. True, but that was not what he wanted.

Dying is always one messy emotional ride, for the patient, for the relatives, and yes, for people like me. For years, it has always been governed by advances in medical technology and the presence of hospitals.

An individual choice of dying is not commonly discussed, and therefore, most of the suggestions and decision-making are left to doctors, who we know will always act to preserve and lengthen your life.

And sometimes the inevitable still happens. Doctors give you "the works," and the patient's heart is indeed left beating, but at what cost? His urine output decreases, he develops gradual swelling of all body parts, and eventually expires --- bloated, pale, with massive pinpoint marks and bruises on all extremities (because of frequent blood-letting), and with tubes inserted in every perceived hole in his body.

Is there dignity in death?

When and how do we know when to stop?

I apologize if I'm ruining your Monday morning.

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