My consultant spoke to me gently, "You know, in the grand scheme of things Candice, uraemia isn't such a bad way to die after all."
...
She had metastatic bowel cancer, and had come in for yet another episode of small bowel obstruction from the extent of her metastatic disease. This was further complicated by her worsening kidney function because both her kidneys were grossly swollen for the same reason.
I was surprised as I scanned through her previous medical notes to see that I had met her before last year when she was an inpatient - despite reading the medical summary I had written, I still could not put a face to the name. I had written then that her oncologist had advised her chemotherapy was failing and that further chemotherapy was unlikely to be beneficial.
But, she's a fighter, this woman.
She insisted then that she wanted to press on with curative chemotherapy, and when I went to see her that night, insisted again that she wanted the kidney surgery it that's what it took to keep her going.
And when I brought up the issue of resuscitation with her, she repeatedly told me calmly - "I will leave it to the Lord. Let His will be done."
When I picked her up from the list of patients awaiting to be seen that night, I knew she was sick. She most certainly had a small bowel obstruction, and her bloods soon revealed that with her declining kidney function was a potassium level of 6.6mmol/L. This was a severe elevation that required immediate treatment, and further increases could well result in cardiac abnormalities and eventually a full blown cardiac arrest.
Her nurse and I got to work immediately. She needed an urgent ECG, intravenous insulin and dextrose to drop her potassium levels, oral contrast, an abdominal CT scan, intravenous albumin, intravenous pain relief, repeat urgent blood tests, a nasogastric tube, a chest XRay, discussion with her usual private specialists, cardiac monitoring, and a signed not-for-resuscitation form.
We managed to bring her potassium down to 5.5 mmol/L, but her blood sugar level came down with that as well to 3.3mmol/L. That needed to be treated with more dextrose, and then her potassium was noted to start climbing again - now 6.1mmol/L.
What we were doing then was simply putting band aid after band aid on an actively bleeding wound. She needed kidney surgery to improve her kidney function, and all the insulin and dextrose in the world was but a temporising measure to attempt to stabilise her. And at this stage, she was by no means a candidate for dialysis.
Her CT scan later revealed a large pelvic metastatic mass that was compressing on her bowels and her kidneys, causing her presentation today. I spoke to her usual private surgeon who accepted her for transfer across to a private hospital where she usually gets care from.
Still, I worried about sending her across to a private hospital late at night with such unstable potassium and sugar levels. So, at the advice of a colleague, I made the decision to call the covering ICU doctor in the private hospital who was aware of this patient being transferred across. I had the intention of updating her of present issues, but was informed instead that her usual team of doctors were planning to discuss withdrawal of treatment and end of life care with her come morning.
...
How do you tell a woman who has been fiercely fighting for so long, that this was going to be her last fight?
...
Stepping back and looking at the whole picture, I knew as well that that was the best thing for her. Her disease had reached a stage where it was overwhelming and no amount of surgery or medicine could fix it. Palliative care was definitely a most rational decision, but after hours of fighting with her, the news came as a surprise.
A dire sense of inevitable helplessness washed over me as I considered her young age and how her time was about to run out. I felt deeply saddened for the fate of this woman and extremely defeated as a clinician.
I know that I am still so, so early in my career and will see many more cases like this in the future.
I know that I've known and treated her for a matter of just hours, whereas other doctors have been tirelesssly fighting with her for years and have gone to even greater measures to help her get just a bit more time.
And yet.. once more, the world simply continued to spin madly on.
...
She had metastatic bowel cancer, and had come in for yet another episode of small bowel obstruction from the extent of her metastatic disease. This was further complicated by her worsening kidney function because both her kidneys were grossly swollen for the same reason.
I was surprised as I scanned through her previous medical notes to see that I had met her before last year when she was an inpatient - despite reading the medical summary I had written, I still could not put a face to the name. I had written then that her oncologist had advised her chemotherapy was failing and that further chemotherapy was unlikely to be beneficial.
But, she's a fighter, this woman.
She insisted then that she wanted to press on with curative chemotherapy, and when I went to see her that night, insisted again that she wanted the kidney surgery it that's what it took to keep her going.
And when I brought up the issue of resuscitation with her, she repeatedly told me calmly - "I will leave it to the Lord. Let His will be done."
When I picked her up from the list of patients awaiting to be seen that night, I knew she was sick. She most certainly had a small bowel obstruction, and her bloods soon revealed that with her declining kidney function was a potassium level of 6.6mmol/L. This was a severe elevation that required immediate treatment, and further increases could well result in cardiac abnormalities and eventually a full blown cardiac arrest.
Her nurse and I got to work immediately. She needed an urgent ECG, intravenous insulin and dextrose to drop her potassium levels, oral contrast, an abdominal CT scan, intravenous albumin, intravenous pain relief, repeat urgent blood tests, a nasogastric tube, a chest XRay, discussion with her usual private specialists, cardiac monitoring, and a signed not-for-resuscitation form.
We managed to bring her potassium down to 5.5 mmol/L, but her blood sugar level came down with that as well to 3.3mmol/L. That needed to be treated with more dextrose, and then her potassium was noted to start climbing again - now 6.1mmol/L.
What we were doing then was simply putting band aid after band aid on an actively bleeding wound. She needed kidney surgery to improve her kidney function, and all the insulin and dextrose in the world was but a temporising measure to attempt to stabilise her. And at this stage, she was by no means a candidate for dialysis.
Her CT scan later revealed a large pelvic metastatic mass that was compressing on her bowels and her kidneys, causing her presentation today. I spoke to her usual private surgeon who accepted her for transfer across to a private hospital where she usually gets care from.
Still, I worried about sending her across to a private hospital late at night with such unstable potassium and sugar levels. So, at the advice of a colleague, I made the decision to call the covering ICU doctor in the private hospital who was aware of this patient being transferred across. I had the intention of updating her of present issues, but was informed instead that her usual team of doctors were planning to discuss withdrawal of treatment and end of life care with her come morning.
...
How do you tell a woman who has been fiercely fighting for so long, that this was going to be her last fight?
...
Stepping back and looking at the whole picture, I knew as well that that was the best thing for her. Her disease had reached a stage where it was overwhelming and no amount of surgery or medicine could fix it. Palliative care was definitely a most rational decision, but after hours of fighting with her, the news came as a surprise.
A dire sense of inevitable helplessness washed over me as I considered her young age and how her time was about to run out. I felt deeply saddened for the fate of this woman and extremely defeated as a clinician.
I know that I am still so, so early in my career and will see many more cases like this in the future.
I know that I've known and treated her for a matter of just hours, whereas other doctors have been tirelesssly fighting with her for years and have gone to even greater measures to help her get just a bit more time.
And yet.. once more, the world simply continued to spin madly on.
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