“I just need a letter to say I am fit to fly,” he says, my young patient who has gone from being a paragon of fitness to needing a walking stick in a space of only two years. Today, he is on an unscheduled visit, promising not to stay long, not that I mind. I’m fond of him and have grown to admire the way in which his family has coalesced at a difficult time. His wife left her job, his pregnant daughter has moved in to help, and his two sons are always around for appointments.
But fit to fly? I’m alarmed.
Fly to where? He is pale and gaunt, his eyes magnified on a cachectic face. But his spirit seems valiant as ever, which sends me scrambling to wonder when we had discussed this impending trip, how it slipped my mind, and most importantly, why I had not encouraged it well before these final days of his life.
A flight from Melbourne to Sydney perhaps. Easy and short. Or further maybe, to Alice Springs — difficult but not impossible. Several times I have stopped palliative chemotherapy to honour a patient’s wish to take a trip.
“Where are you flying?” I ask.
“Asia.” he says, and I do a double-take. “They have curative treatment there.”
I should have guessed.
“There is this famous hospital where they give special therapy to kill cancers that have stopped responding to chemo. They sound amazing.”
Every oncologist spends time drawing a distinction between useful adjunctive therapies including reflection, meditation and exercise and dangerous extreme alternatives like exclusion diets and vitamin overdoses, but judging by his tone I calculate that my time would be more wisely spent trying a different approach.
“I am worried about you deteriorating while overseas in a country that has poor hospitals and no palliative care services. I’d hate for you to be stuck.”
“I’ve spoken to them, they can fix me,” he says.
“They can’t fix you,” I gently respond. “I know this is really difficult but stay here and let us help you. At least give it some thought.”
Brandishing a manila envelope, he says, “The flight is booked, we leave tomorrow.”
Many retorts, pleas, and memories of misadventure cross my mind, still I hold my tongue, understanding that the measure of grief and the promise of hope amount to much more than the weight of my frustration.
“Doctor,” says my patient. “You have nothing further to offer me, please don’t block my way.”
We arrive at the impasse we had to have.
“I won’t change your mind but I can’t declare you fit to fly,” I say.
At this, I think of the times I have been called to assist ill patients on long-haul flights. Many were emergencies but some not. An elderly lady had felt unwell throughout that day’s dialysis and subsequently suffered an arrest on the plane. “Who cleared her to travel?” I plaintively asked her husband as she drifted in and out of consciousness.
Her situation had stressed hundreds of passengers, distracted the pilot, and put a nurse and me in the impossible situation of resuscitating a patient with bare resources and deafening noise.
I regard my desperate patient with something of my own desperation as I ponder my duty of care. Is it to my patient, reliant on me for a final morsel of hope? Or to all the unseen travellers who may be inconvenienced if by chance he falls ill on the flight?
To temper my pessimism, I remind myself of the grateful patients who didn’t succumb to my dire predictions. The breathless Greek patient who had lived his entire life in Melbourne but who got hold of oxygen and begged to die on home soil. The grandmother who decided that the only way she could make amends to her estranged daughter was to embrace her grandchildren who lived in Egypt. The patient who braved a trip to India by ingesting extra morphine and whose wife wrote to say his final weeks with his whole family had been the most consoling.
This man’s reasons were different but who was I to be impatient around, and judgemental about, people whose decisions departed from mine? So with my patient watching I write the most honest letter I can. It states his wish to seek treatment in a foreign country, my opinion that patients like him can deteriorate unexpectedly, and my sincere hope that he remains safe. He deems the letter fair; his family is clearly displeased.
I feel rattled until I hear that the flight was uneventful. But then the heartache continues because the treatment centre “took one look at him and told him to turn around and go back home”. Which he manages to do before plunging into further decline and succumbing to his illness a short time later in a trajectory that had been predicted.
In the ensuing months the family resists all contact, perhaps feeling angry and let down by all the people who failed their loved one. Meanwhile, the team, too, lacks closure and feels inadequate at not being able to prevent preventable suffering at the end of life.
We muse that perhaps the hardship would have felt worse had they not pursued this last avenue of hope. And maybe the only thing left to give a vulnerable patient is the gift of autonomy. These and other thoughts swirl in my mind, no doubt to be tested in the case of another patient and another patient after that, with every outcome testing and unsettling in its own way.
So many advances in cancer, so many protocols, but still missing is the protocol that says, dispense just this much fact, mix just so much optimism, offer precisely this much warning, infuse just so much hope and things will turn out fine. For doctors, it’s about how to stand up to — and stand by — our patients to give them the very best of medicine but shield them from the worst. For patients — when to question their own discussions and when to place their trust in ours.
On many days, this seems to be the impossible quest.
— Guardian News and Media Limited
Dr Ranjana Srivastava is an Australian oncologist and an award-winning author. Her latest book is After Cancer: A Guide to Living Well.
