LBBERSAMIN’S MAR [15-06]: A Patient’s Passage with Dignity

Medical Anecdotal Report
Indexing Title: LBBERSAMIN’S MAR [15-06]
MAR Title: A Patient’s Passage with Dignity
Date of Medical Observation: June 2015
Tag: Providing care for a terminally ill patient even if with a do-not-resuscitate status
Category: Professional/Ethical– Reinforcement
Narration
I was endorsed a 16-year-old male patient with a fungating mass the size of a volley ball in the proximal aspect of his right leg. The patient was previously seen and managed by a different institution and was last seen 4 months ago but was lost to follow-up due to the financial misunderstanding in management. He was diagnosed with osteosarcoma stage II then. After some time, seeking some help from close people, the patient was sent to me for management and care. As I first saw this patient, I asked about the history of his illness from him and his relatives. I talked to him a little and tried to convey my authoritative concern. I went through my physical examination and his medical files to seek a better grasp of what was done to him before in the other institution. “Tulungan nyo po kami doc” (Help us doctor!), the aunt said.  I knew that he was in poor condition. The patient was noted to have mild laboured breathing, matted lymph nodes in the inguinal area, on top of the obvious problem of the 20 x 25 x 10 cm fungating mass. I also noted a suspicious lesion in the right lung field of his chest radiograph. I referred the patient to our orthopaedic consultant and sought the services of our oncologic surgeon and the pediatric department. After providing the patient the initial management at the emergency department, we admitted him under our service. I pooled the relatives prior to admission and told them that the patient was already in a bad state and time had played a role for the cancer spread. The patient was already with a stage IV cancer disease with the probability of pulmonary metastasis. The patient was seen by different services I had on board and had explained to the patient and the relatives of the unfavourable facts. The relatives broke into tears but responded with a level of understanding and acceptance in that somehow, they knew all along. Two days after admission, the patient went into cardiac arrest. But after the first cycle of cardio-pulmonary resuscitation and intubation, the patient was revived. I informed the relatives of the patient’s current condition and what the arrest meant for the patient’s chance of survival. I told them upfront that he has little chance of surviving this state and that the extraordinary measures provided to him will be what prolongs him. I explained to them the do-not-resuscitate status which they can consider now and that the family should make preparations. I told them that even in this state, we will still be providing the pulmonary support, fluid and nutritional sustenance, and wound care. I even coordinated with the pastoral office to convey the patient’s last rites. As I went about to see him each day, I checked if he was given the decency of care from being suctioned, the provision of medications, oral and body hygiene. On one occasion, I went out to reprimand a nurse for not providing my patient the scheduled feeding. Then, through the night, as I was home, my patient came to pass. I called my co-residents on duty to assist the relatives in as much as they can. The mother then called me, thanking me of the help we had provided them and said that his son’s passing could not have been more bearable if not for the understanding and care of us doctors.        
INSIGHT                                                                                                                                                 
(Physical, Professional/Ethical, Psychosocial)
(Discovery, Stimulus, Reinforcement)
Death is not new to us doctors of this institution. We have witnessed it in some of our patient’s and as we have come to know from history that death is just a part of life. We can always recall our past patient’s who ended up with this fate and its significance in medicine. But what broad characterization of death can we give if our patient’s had to suffer in dying. We come to read so much about the types of cancer and the prognosis in each of the illnesses stages. Some types are worst than the others. We come to give facts about terminal illnesses to our patients and be truthful about everything. We give them the most reasonable and acceptable method of care for terminal illnesses. But in this conveyance of facts, we encounter patients and relatives, bargaining, or in a state of denial, unable to understand their disease process. Sometimes the information cannot be conveyed to patients by a single doctor. A multidisciplinary team of specialists may provide this deep set of facts and confluence of information, often too much to grasp especially in cancer patients. When our patients succumb to this state of their illness, where no measure of cure can be given, doctors should provide the utmost quality palliative care. In terminally ill patients in coma, relatives see the reality and morbid picture of this circumstance in their illness. And in this state, relatives then decide to place their patient in a do-not-resuscitate (DNR) status. Even with this DNR status, we have to be able to provide their needs as we do in recovering patients. We should still provide all the care necessary to set a margin of decency to life. But other than the priority support we give, the ventilator support and nutrition; it matters also to the relatives the little things.  We should also be able to provide our terminally ill patients the decency of care as we do in healthy patients.   

ROJoson’s Notes (17jan20):

Physicians should properly care for the terminally-ill patients with holism, professionalism, and compassion.  Give realistic and effective palliative care that they do not suffer much.
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