Taureef Mohammed
THREE WEEKS into palliative care, I am yet to see a patient with cancer. Instead, I am seeing all the patients (not the actual same patients) who, a few years ago, I saw on the internal medicine ward: patients with heart failure, dementia, end-stage kidney disease, liver disease, COPD (chronic obstructive pulmonary disease). I am asking them questions that I would not have routinely asked as an internal medicine resident: What matters most to you right now? Do you want to return to hospital? Where do you want to die?
These questions may seem difficult, but they are usually the easier parts of the conversation. What is not always straightforward is the question that comes before: What do you understand about your illness? If they fully understand, then the subsequent questions are easy. Sometimes more than one conversation is needed, which was the case for a patient I recently saw.
“I am so confused!” the frail elderly man said. He grimaced, his eyes closed, as he overcame his breathlessness to express his exasperation. I am doing a terrible job at explaining the progression of his disease (heart failure), I thought. I was trying to explain that he was dying from heart failure. I drew him a graph. I wonder now if that confused him even more.
I glanced at his relative at bedside to see if she appeared confused too. She did not. I wondered if she knew he was declining, dying. Perhaps she’d seen it: his recurrent admissions to hospital for “fluid in his lungs,” his declining mobility at home, her having to do more for him. Perhaps she knew where I was getting at: the end was near.
I told him to think over what we spoke about, hoping that the relative could make things a bit clearer for him once I left.
Around the same time, I met a co-resident in the residents’ lounge. He told me how he did a rotation in home palliative care sometime ago and found it very helpful. I told him about how grey and difficult the conversations felt.
“It’s easier with cancer, you know, the big C. They are expecting a conversation about dying and death. Also, the nature of cancer makes the conversation easier.”
He added: “Someone with COPD admitted over and over to hospital with an exacerbation is dying too, but they don’t see it as that.”
He hit the nail on the head. There were articles in the medical literature describing the difference.
A diagnosis of cancer brought death into the conversation. On receiving a cancer diagnosis, patients hoped for the best but had the worst on their mind. The trajectory of cancer was more predictable than non-cancer, life-limiting diseases like heart failure, COPD, kidney failure. When cancer – which came from the Greek word for crab, named so by Hippocrates because of the way tumours seemed to spread out like the legs of a crab – progressed, it followed a predictable path: initially a slow, gentle decline, followed by a steep, rapid decline.
Diseases that affected a particular organ – like heart failure, kidney failure, COPD – followed a less predictable path. They pr
