One of the hardest tasks for a cancer specialist to deal with is to face the family when a patient dies. No matter how much counselling and discussion has gone into preparing them for the inevitable, it is often difficult to predict how the family will react to the actual demise of their loved one.
Mr Li was a 51 year old Chinese researcher, who was born in Beijing, but has lived in the United States for many years. He was first diagnosed to have Stage 2 kidney cancer, for which surgery was carried out in March 2007.
Within two years, his cancer recurred. Initially, it affected the lungs, but eventually spread to the bones.
He was extensively treated in the U.S. with the whole range of targeted drugs.
Sorafenib (Nexavar®) and Sunitinib (Sutent®), two established medicines in the treatment of metastatic kidney cancer, had already been used. While there was some initial improvement, the disease eventually progressed as the cancer cells developed resistance to the treatment.
Radiotherapy had also been deployed to treat the bone metastases.
I am not sure why he decided to come to Singapore to see me but I first met him on 31 March 2014. At that stage, he was already in a bad state as he had severe pain from metastases to the bones.
He also complained of coughing out blood caused by lung metastases and a low platelet count.
His cancer was widespread, involving the spine, lungs, lymph nodes and in the abdomen.
There was serious concern as the cervical spine (meaning the bones surrounding the spinal cord at the back of the neck) had been badly affected by cancer.
The neurosurgeon who consulted on the patient explained that there was a high risk that the spinal cord would eventually be affected and that he could become paraplegic (paralysed in both legs). As the disease was too advanced, surgery was not advisable as the spine was unstable.
We discussed the option of doing nothing (meaning to go back either to China or the U.S.). However, Mr Li was not prepared to give up and wanted treatment.
Left with little choice, I came up with a cocktail of chemotherapy drugs combined with immunotherapy. I explained that this a rather desperate attempt to control the disease.
After two months of treatment, the PET-CT scan in June 2014 miraculously showed that the cancer had responded in all the sites.
As the treatment had to be administered once every two weeks, Mr Li, accompanied by his faithful wife, had to fly in to Singapore fortnightly.
In between the treatment visits, he would sometimes stay in Singapore, or travel back and forth to Beijing, Shanghai, Hong Kong or the U.S.
On the 17 March 2015, I received a frantic call from his friend that he was coughing out blood. I advised her to quickly call an ambulance to bring him either to see me or the nearest hospital.
Not long after, I was on the line with the ambulance nurse, who informed me that despite their best efforts at resuscitation, Mr Li had passed away.
I had just seen him just four days earlier when he came for his fortnightly treatment. He was in reasonably good health. He was looking forward to his son’s visit to Singapore. It was a shock to me that he would pass away so suddenly.
I imagined that his family must be even more distraught and probably angry with me.
Less than a week after the event, my staff informed me that his wife was outside in the waiting area and had requested to see me.
I braced myself and muttered a silent prayer.
When she came into the room, she spoke of her deep appreciation for all that I had done for her husband. She related, in very eloquent Chinese, how much her husband appreciated the care that I had given him.
He had told her that I was more than a doctor to him. He considered me his friend and brother. As she went on and on, she wept openly as my eyes teared.
She went on to describe the final event. They had been shopping that morning followed by lunch with their son. After coming home from lunch, he suddenly started coughing out massive amounts of blood. Her son, who is a doctor, shooed her out of the room as he tried his best to resuscitate his father.
Despite his best efforts and the assistance for the ambulance team, Mr Li passed away.
She told me that the last one year meant a lot to them. While the final event was traumatic for her, she was glad that the end was swift and painless for him.
She went on to explain her plans to bring his ashes back to the U.S. and then eventually to Beijing.
After one final hug, she left.
I had to compose myself for a short while before I could carry on seeing patients.
The eventual death of cancer patients is largely expected as up to 70 per cent of my patients present with Stage 4 disease. But the drama and suddenness of the final event can sometimes take us by the heart.
The reaction of the family to a patient’s death is equally unpredictable. Some are appreciative of the fact that we have done our best. Others feel that we have not done enough.
My Chinese has never been good enough for anything but the most functional of conversations but I think Mrs Li could see that I too, felt the loss of a friend and a brother.
By Dr Ang Peng Tiam