Tough Call: Saving Lives and Souls

I just admitted a 95-year-old woman with a recent history of clostridium difficile colitis who presented with abdominal pain, fever, and leukocytosis to the emergency department and was found to have peritonitis and free air on chest X-ray. She was in pain, uncomfortable, but alert and oriented and able to participate in the discussion about goals of care. One could certainly consider whether or not antibiotics would be palliative in this case. Could they possibly help the inflammatory reaction and thereby assist with pain control? They could potentially prolong her life. In my discussion with her and her POA, a niece, we discussed her recent quality of life and her life goals. She tells me that she had to move into the nursing home several months ago and her quality of life has dramatically decreased since leaving her assisted living apartment. She is no longer in control and needs help with routine activities. These losses have really diminished her autonomy and quality. We talked briefly about anything she felt she had left to accomplish before she died. Thus after a brief life review I felt I was in a position to help her with decision making. My impression was of a lady who was at the end of her life, both physically and psychologically, who now has a mortal complication of colitis. Given the context of her life, I recommended an approach that focused on her symptoms only, without any attempts made to treat the underlying infection. The patient seemed relieved and said, “I’m old, I’m tired, I’m ready to go.” I admitted her to my inpatient palliative care medicine unit where we will focus our efforts solely on her comfort and provide emotional support to the patient and family. Although I’m not saving her life, I hope we can help save her soul, and those of her loved ones, by minimizing any suffering at the end of her life.

I think it’s critical to take the time to understand the patients’ life story and their perspective on illness before making recommendations for treatment. Perhaps this case, in a 95 year old with peritonitis, is easier to conceive but the principles are the same irrespective of age and diagnosis. Understanding a patient’s perspective on cancer should be the first step in making a treatment recommendation, especially in the palliative setting. The only way to really get a handle on that perspective is to spend a few minutes understanding the story of the patient. And you will be amazed at all the wonderful things you will learn that will enrich both your understanding of the patient and your own life.