Friday, December 7, 2012


   I often say that one does not have 'choice ' in determining when one is born , and when one dies . One does not have choice in determining as to who are his parents . In a way this accurate and to some extent it is good . But one can argue that sometimes one can determine the time of death , as in case of suicide . But I am talking about normal , natural death . But in medicine I have seen that sometimes patients can decide as to when they want to die .
    I had known this patient, Mary for long time . I treated her husband too . He was much older that her and one day he died in the hospital . He was also my office patient . So he had an appointment with me in the office that was made long before he was admitted to the hospital.. Unfortunately my office did not cancel it , in the computer and ended up calling his home to 'confirm ' the appointment . She was quite mad , as we did not 'know 'that he had died . I continued to treat her for her asthma.
    One day she was admitted to the hospital . I was called in to manage her asthma . She was not feeling good and was having very vague symptoms . She low grade fever , that many times could not be confirmed , as she would 'feel' warm and hot , but the temperature was normal .She also would have sweating and had some issues with the weight loss , which was not major . The family doctor and the infection disease specialist had done the work up and did not find a reason and felt that it was due to menopause . According to her she had menopause many years ago and these symptoms had started only recently . I was not too sure as to the cause of her complaints and her lungs were 'fine ' . I was little concerned about the possibility of a occult "lymphoma " , a lymph node cancer . (the cancer can spread to the lymph nodes , but when the lymph node it self starts the cancer it is called lymphoma . ). I did do the CT scan of the abdomen and there was some abnormality . I decided to call a surgeon and he opened her up and found out a tumour called CARCINOID . This tumour is one such tumour that can be called either 'a benign tumour that sometimes spreads or metastasises ' or it can be called a cancerous tumour that grows very slowly and rarely metastasises . 'It also sometimes can secrete chemicals that cause the symptoms that Mary was having . Mind you this happened about 22 or 25 years ago . At that time specific type of  scanning for this type of tumour was not there.
    She was cured ! (she did get similar symptoms latter on and we could not find source of any recurrence , but she did respond to the treatment of carcinoid  with drugs .) This turned around her feelings about me as a doctor and I was the only doctor that she trusted . Our relationship continued to grow as I saw her for several years . She was admitted to hospital with asthma and continued to have some fever . The primary care doctor treated her for 2 days and then called . I told her that most likely her fever was due to urinary tract infection and not lung infection . So I changed her antibiotic and did urine culture and it did come back positive for the bacteria that was not sensitive to the antibiotic that she was getting before I saw her . (though it was good antibiotic for bronchitis . )
   Next time she was admitted she had lower back pain and the doctor suspected urinary infection . The urine culture came OK and then I was called in , not because of lung problem , but it was a consult at her request . I found out that she had fracture vertebra and it was due to osteoporosis and had her do procedure , where they put a glue or cement . Her was 80 % gone . Again I was the hero .
   I continued to see her in the office . She was almost ninety . And she was admitted to the hospital . Had bad bronchitis, pneumonia . She also had bad heart for last 5 years and had irregular heart beats . Interestingly she had avoided being in the hospital in spite all these problems for last 3 years . I started he treating her , so did the cardiologist . Nothing had changed much in cardiology part , but I was quite limited in treating her for the lungs as her heart rate was continued to be a problem . She was not bad , but did not get better as was expected .On 3rd or 4th day I went to see her in her room . The nurse was with me . She was on medicine for her heart rate , but it was still up . She was awake , alert , fully oriented , was not in distress , but was quite congested . She was unable to cough up . I examined her and was talking to the nurse about change in her treatment , she stopped  me . She took my hand in her hand and said , "Doctor , how long we have known , each other . ( it was not a question but a statement .)There is no one that I trust more than you and I will really miss you . but it is time to depart ." I understood what she meant . She continued . " Please let me die peacefully . I just want to be comfortable ."
     I called her family , made her DNR , stopped her all labs, x-ray and work up . I did not stop her medicine. She died in less than 24 hrs !!!!!
  I do believe that the out of all our attachments in this world , (eating , sex , music drug addictions , ) attachment to the body or to 'live ' is most powerful and we can rarely get away from it .

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