Gatekeeper

One evening as the oncology fellow on call, I received a phone call from the ICU fellow.

“Can you meet me in the emergency room?” he asked. “I want to make sure we’re on the same page.”

A patient we had discharged from the hospital 2 days before was back. He had metastatic stomach cancer that had spread into his lungs and the lymph nodes in his chest. While he was in the hospital, he had required several liters of oxygen to maintain a normal work of breathing.

But now, he was in the emergency room, he was requiring a full face mask to help him breathe – and his oxygen levels were still dropping.

The ICU had been called. The next step along the algorithm of worsening breathing would be intubation. They would have to sedate him, put a breathing tube down his throat, and connect him to a ventilator to keep him alive.

But they didn’t want to do that if he was dying from his cancer.

Hence the call to me. My job, as the oncologist on call, was to answer the question: Is he dying?

Specifically, that meant weigh in on his cancer prognosis. Put his disease into context. Does he have any more options, chemotherapy or otherwise?

As an oncology fellow, I’ve found this to be one of the most common calls I get. Someone is critically ill and they need something to survive – maybe it’s intubation; maybe it’s surgery. The patient also happens to have metastatic cancer. The question posed to me is: Should we proceed?

It’s also one of the most difficult calls. Because doctors are historically bad at prognosticating. Because often I’m meeting the patient for the first time. Because the decision is huge and often final, and because both options are bad.

Suppose I say he has a good year or 2 ahead of him, and we intubate him – and then he never comes off the ventilator. We are eventually forced to withdraw care, and to the family it’s as though they are killing their father. It’s traumatic; it’s painful; and it deprives someone of a comfortable passing. Suppose I say he is dying from his cancer and we decide against a breathing tube. If I am wrong in that direction, a person’s life is cut short. It’s a perfect storm of high risk and low certainty.

Many people with metastatic cancer say they wouldn’t want invasive treatment near the end of life. But how do we know when it’s the end? There is still a moment when you must determine: Is this it? The truth is it’s not always clear.

 

Whenever I can, I reach out to the primary oncologist who knows the patient best. Then, I do a quick search for something reversible. Did the patient take too much morphine at home, and should we trial a dose of Narcan? Does he have a pneumonia that could be cured with antibiotics, a blood clot that could improve with blood thinners, or some extra fluid that can be diuresed? But usually it’s a mix, and even if there is a reversible injury, it can tip the very ill person over to the irreversible. This is how passing away from an aggressive cancer plays out.

Down in the emergency room, my patient’s breathing is rapid. His chest is heaving. The nurse shows me his blood gas with a carbon dioxide level more than twice the upper limit of normal. Now fading in and out of consciousness, he is a different man from the one who had walked out of the hospital 2 days earlier.

His daughter stands next to him. “He always said he wanted to do everything. I think we should give the breathing tube a try,” she says.

I tell her my concerns. I am afraid if we do it the likelihood of ever coming off is slim. And if we place a breathing tube he would have to be sedated so as not to be uncomfortable, and you won’t be able to communicate with him. You can’t say good bye, or I love you. If we keep the mask, he may wake up enough to interact.

The daughter – whom I knew well from prior visits, who was always articulate and poised and the spokesperson for the family – had held it together this entire time. Now, she breaks down. We all wait as I hand her a box of tissues. I look down, channeling all of my energy into not crying in front of her.

He’s waking up, one of us notes.

She goes over. “I need to ask him,” she says.

“Papa.”

At first he doesn’t answer.

“Papa, do you want the breathing tube?”

“No,” he says.

“Without it you can die. You know that, Papa?”

“No breathing tube,” he says.

“OK,” she turns to us, with tears of sadness but also what seems like relief.

Forty-eight hours later, he passed away. His family had time to come in, and he had periods of alertness where he could speak with them. They were able to say good-bye. He was able to say I love you.

Another patient’s wife once told me he had given her the “gift of clarity” when he plainly stated before he passed that he didn’t want to be saved. She didn’t have to make the decision for him, and neither did the doctors. I liked that term, and I thought about it then.

I am grateful my patient’s wishes were clear. But we aren’t always so lucky. It’s a chilling part of the job description, being a gatekeeper to the question: Is this the end?

Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.

One evening as the oncology fellow on call, I received a phone call from the ICU fellow.

“Can you meet me in the emergency room?” he asked. “I want to make sure we’re on the same page.”

A patient we had discharged from the hospital 2 days before was back. He had metastatic stomach cancer that had spread into his lungs and the lymph nodes in his chest. While he was in the hospital, he had required several liters of oxygen to maintain a normal work of breathing.

But now, he was in the emergency room, he was requiring a full face mask to help him breathe – and his oxygen levels were still dropping.

The ICU had been called. The next step along the algorithm of worsening breathing would be intubation. They would have to sedate him, put a breathing tube down his throat, and connect him to a ventilator to keep him alive.

But they didn’t want to do that if he was dying from his cancer.

Hence the call to me. My job, as the oncologist on call, was to answer the question: Is he dying?

Specifically, that meant weigh in on his cancer prognosis. Put his disease into context. Does he have any more options, chemotherapy or otherwise?

As an oncology fellow, I’ve found this to be one of the most common calls I get. Someone is critically ill and they need something to survive – maybe it’s intubation; maybe it’s surgery. The patient also happens to have metastatic cancer. The question posed to me is: Should we proceed?

It’s also one of the most difficult calls. Because doctors are historically bad at prognosticating. Because often I’m meeting the patient for the first time. Because the decision is huge and often final, and because both options are bad.

Suppose I say he has a good year or 2 ahead of him, and we intubate him – and then he never comes off the ventilator. We are eventually forced to withdraw care, and to the family it’s as though they are killing their father. It’s traumatic; it’s painful; and it deprives someone of a comfortable passing. Suppose I say he is dying from his cancer and we decide against a breathing tube. If I am wrong in that direction, a person’s life is cut short. It’s a perfect storm of high risk and low certainty.

Many people with metastatic cancer say they wouldn’t want invasive treatment near the end of life. But how do we know when it’s the end? There is still a moment when you must determine: Is this it? The truth is it’s not always clear.

 

Whenever I can, I reach out to the primary oncologist who knows the patient best. Then, I do a quick search for something reversible. Did the patient take too much morphine at home, and should we trial a dose of Narcan? Does he have a pneumonia that could be cured with antibiotics, a blood clot that could improve with blood thinners, or some extra fluid that can be diuresed? But usually it’s a mix, and even if there is a reversible injury, it can tip the very ill person over to the irreversible. This is how passing away from an aggressive cancer plays out.

Down in the emergency room, my patient’s breathing is rapid. His chest is heaving. The nurse shows me his blood gas with a carbon dioxide level more than twice the upper limit of normal. Now fading in and out of consciousness, he is a different man from the one who had walked out of the hospital 2 days earlier.

His daughter stands next to him. “He always said he wanted to do everything. I think we should give the breathing tube a try,” she says.

I tell her my concerns. I am afraid if we do it the likelihood of ever coming off is slim. And if we place a breathing tube he would have to be sedated so as not to be uncomfortable, and you won’t be able to communicate with him. You can’t say good bye, or I love you. If we keep the mask, he may wake up enough to interact.

The daughter – whom I knew well from prior visits, who was always articulate and poised and the spokesperson for the family – had held it together this entire time. Now, she breaks down. We all wait as I hand her a box of tissues. I look down, channeling all of my energy into not crying in front of her.

He’s waking up, one of us notes.

She goes over. “I need to ask him,” she says.

“Papa.”

At first he doesn’t answer.

“Papa, do you want the breathing tube?”

“No,” he says.

“Without it you can die. You know that, Papa?”

“No breathing tube,” he says.

“OK,” she turns to us, with tears of sadness but also what seems like relief.

Forty-eight hours later, he passed away. His family had time to come in, and he had periods of alertness where he could speak with them. They were able to say good-bye. He was able to say I love you.

Another patient’s wife once told me he had given her the “gift of clarity” when he plainly stated before he passed that he didn’t want to be saved. She didn’t have to make the decision for him, and neither did the doctors. I liked that term, and I thought about it then.

I am grateful my patient’s wishes were clear. But we aren’t always so lucky. It’s a chilling part of the job description, being a gatekeeper to the question: Is this the end?

Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.

One evening as the oncology fellow on call, I received a phone call from the ICU fellow.

“Can you meet me in the emergency room?” he asked. “I want to make sure we’re on the same page.”

A patient we had discharged from the hospital 2 days before was back. He had metastatic stomach cancer that had spread into his lungs and the lymph nodes in his chest. While he was in the hospital, he had required several liters of oxygen to maintain a normal work of breathing.

But now, he was in the emergency room, he was requiring a full face mask to help him breathe – and his oxygen levels were still dropping.

The ICU had been called. The next step along the algorithm of worsening breathing would be intubation. They would have to sedate him, put a breathing tube down his throat, and connect him to a ventilator to keep him alive.

But they didn’t want to do that if he was dying from his cancer.

Hence the call to me. My job, as the oncologist on call, was to answer the question: Is he dying?

Specifically, that meant weigh in on his cancer prognosis. Put his disease into context. Does he have any more options, chemotherapy or otherwise?

As an oncology fellow, I’ve found this to be one of the most common calls I get. Someone is critically ill and they need something to survive – maybe it’s intubation; maybe it’s surgery. The patient also happens to have metastatic cancer. The question posed to me is: Should we proceed?

It’s also one of the most difficult calls. Because doctors are historically bad at prognosticating. Because often I’m meeting the patient for the first time. Because the decision is huge and often final, and because both options are bad.

Suppose I say he has a good year or 2 ahead of him, and we intubate him – and then he never comes off the ventilator. We are eventually forced to withdraw care, and to the family it’s as though they are killing their father. It’s traumatic; it’s painful; and it deprives someone of a comfortable passing. Suppose I say he is dying from his cancer and we decide against a breathing tube. If I am wrong in that direction, a person’s life is cut short. It’s a perfect storm of high risk and low certainty.

Many people with metastatic cancer say they wouldn’t want invasive treatment near the end of life. But how do we know when it’s the end? There is still a moment when you must determine: Is this it? The truth is it’s not always clear.

 

Whenever I can, I reach out to the primary oncologist who knows the patient best. Then, I do a quick search for something reversible. Did the patient take too much morphine at home, and should we trial a dose of Narcan? Does he have a pneumonia that could be cured with antibiotics, a blood clot that could improve with blood thinners, or some extra fluid that can be diuresed? But usually it’s a mix, and even if there is a reversible injury, it can tip the very ill person over to the irreversible. This is how passing away from an aggressive cancer plays out.

Down in the emergency room, my patient’s breathing is rapid. His chest is heaving. The nurse shows me his blood gas with a carbon dioxide level more than twice the upper limit of normal. Now fading in and out of consciousness, he is a different man from the one who had walked out of the hospital 2 days earlier.

His daughter stands next to him. “He always said he wanted to do everything. I think we should give the breathing tube a try,” she says.

I tell her my concerns. I am afraid if we do it the likelihood of ever coming off is slim. And if we place a breathing tube he would have to be sedated so as not to be uncomfortable, and you won’t be able to communicate with him. You can’t say good bye, or I love you. If we keep the mask, he may wake up enough to interact.

The daughter – whom I knew well from prior visits, who was always articulate and poised and the spokesperson for the family – had held it together this entire time. Now, she breaks down. We all wait as I hand her a box of tissues. I look down, channeling all of my energy into not crying in front of her.

He’s waking up, one of us notes.

She goes over. “I need to ask him,” she says.

“Papa.”

At first he doesn’t answer.

“Papa, do you want the breathing tube?”

“No,” he says.

“Without it you can die. You know that, Papa?”

“No breathing tube,” he says.

“OK,” she turns to us, with tears of sadness but also what seems like relief.

Forty-eight hours later, he passed away. His family had time to come in, and he had periods of alertness where he could speak with them. They were able to say good-bye. He was able to say I love you.

Another patient’s wife once told me he had given her the “gift of clarity” when he plainly stated before he passed that he didn’t want to be saved. She didn’t have to make the decision for him, and neither did the doctors. I liked that term, and I thought about it then.

I am grateful my patient’s wishes were clear. But we aren’t always so lucky. It’s a chilling part of the job description, being a gatekeeper to the question: Is this the end?

Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.