“Nothing in life is certain except death and taxes!” my dad often crows.
This phrase takes me back to my boyhood, watching the Cricket World Cup matches with him. Time and again, I would pray fervently for an Indian win, but watch in increasing desperation as India threw away an insurmountable lead and snatched defeat from the jaws of victory.
My dad’s demeanor never changed; he was ever the dispassionate observer. When India succumbed to Australia in the 2003 World Cup, his mustachioed lip barely quivered.
“Nothing is certain–especially not India winning,” he said, a bit more quietly than usual.
As a resident physician working in both internal medicine and pediatrics, I’ve observed that everyone who works in an intensive-care unit develops this same somber realism, particularly when it comes to impending death.
Sometimes this manifests as a vague sense of foreboding over an octogenarian patient with multiple comorbidities who’s survived the current hospitalization, but may not live to see the next.
Other times, the unease is stronger, as with Mr. Knight–a middle-aged gentleman with a wife, three young children and metastatic liver cancer. Initially treated at a different hospital, he’d undergone multiple rounds of chemotherapy. His body had been ravaged by both his disease and its treatment, and eventually his physicians had said they could do nothing more. They had discharged him home with hospice care, to spend his last days with his family.
Mr. Knight’s family did not share the doctors’ pessimism, however. A few days later, his family found him difficult to arouse and brought him to my hospital’s emergency department. As an ICU resident, I went to the ED to evaluate him.
Like any good resident, I didn’t walk into this encounter blind. I had read Mr. Knight’s labs, seen the lactate of 16 (very high), glanced at his CT scan and seen that his entire abdomen was taken up by cancer. I walked into the room armed with my stethoscope, my white coat, my knowledge that a lactate of 16 was bad, and my certainty that Mr. Knight was going to die. Soon.
As I walked in, Mr. Knight’s wife, father, mother and sister all started talking. His father’s face lit up. I could practically read his mind: Here’s an Indian doctor who will understand us, and not give up on my son like all the foreign doctors.
“Until just a few months ago, my son was completely healthy,” he said in Hindi, clearly hoping to forge a personal connection. “He was playing cricket in his local league…Do you watch cricket?” Beneath the words, I heard his unspoken plea: Surely there’s some way you can help my son get better.
At the same time, Mr. Knight’s sister asked, in English, “Why is he so sleepy?” And his wife piped hopefully, “Can I feed him something? Do you think he is tired because he hasn’t eaten anything?”
My mind flitted back to the 2003 cricket match.
“Will Ricky Ponting get out?” I’d asked my dad repeatedly, hopefully, desperately. Ponting, the Australian captain, was in fine form. He swatted the Indian bowlers around the field, showing no signs of getting out.
I looked at Mr. Knight, lying on the stretcher. He had a full head of hair and a young face free of wrinkles. But his eyes, like his skin, were a dark, sickly yellow–the yellow of a highlighter that has long since run out of ink. His abdomen bulged out–filled, as I knew, with cancer and cancer-induced fluid. He lay taking deep breaths, as though sighing at what his life had come to.
“How are you feeling?” I asked, not expecting a detailed reply but hoping to see how alert he was.
“I want to go home….” he croaked.
His sister rushed to his side and grabbed his arm.
“Tell him you want to fight!” she yelled. Then she turned to me.
“He wants to keep fighting,” she said matter-of-factly. “Please do everything you can to save him.”
But the lactate! I shouted internally. His CT scan is all liver, and nothing else! Have you seen his blood pH?
I wanted to assault her with these medical facts–but I decided that the ED was no place for this.
“He is very sick, and the cancer has taken over a lot of his body, but we’ll do our best,” I said, offering the noncommittal postponements I’d been trained to say.
Over the next few days, the medical team talked to Mr. Knight’s family about his grim prognosis. His wife agreed to make him DNR (Do Not Resuscitate); his sister forced her to revoke it.
On day three, Mr. Knight was again discharged with home hospice care–only to return the next day and be readmitted. (This was one of the most surreal moments in my training. After working a twenty-eight-hour shift, I left the hospital thinking that Mr. Knight was finally going home to die in peace with his family. Twelve hours later I returned to find him back in the ICU, just in a different room.)
Throughout all of this, no one on the medical team felt anything but certain how it would end. In my mind, Mr. Knight’s march towards death was as inexorable as Australia’s march towards the cricket championship, all those years ago.
I wonder if my dad had ever felt exasperated, seeing my naïve hopes for the Indian team year after year. From time to time he’d tried to reason with me, showing me stats and explaining how our bowling was just never good enough. He’d tried to lower my hopes–maybe reaching the semifinals was good enough! He was always realistic; I was always hopeful.
In the end, what could he do, when I wanted so badly not to believe him?
Mr. Knight’s medical team was always certain, but his family was so uncertain, because they felt hopeful. Hoping for a miraculous recovery, they vacillated painfully–first accepting hospice care and then launching a full-court press to save him, all within a twelve-hour span. Into the chasm between his doctors’ certainty and his family’s uncertainty fell Mr. Knight.
Over Mr. Knight’s next few days in the hospital, his body fluids started leaking out of his blood vessels and onto his skin. His edema worsened until his eyes were swollen shut and his lower eyelids turned outward, revealing the pink inside. His skin wept fluid, as though trying to make up for the tears his eyes could no longer produce. He started bleeding from his gums and all around the breathing tube in his mouth. He also bled from the IV lines in his neck and arms, and from around the tubes in his urethra and rectum.
About two weeks after Mr. Knight was first hospitalized, as he lay in the same ICU with only the solitary room change to tell the passage of time, his brain herniated through his skull, and he died.
Mr. Knight’s fate showed me the value of accepting reality, of letting go of unreasonable hope, and making the most of what little time is left us. But so often in medicine, hope and reality seem to be in conflict–and sometimes, hope is rewarded. The hard part is knowing when to accept reality and when to hope.
That same year, a few months after Mr. Knight died, India won the World Cup.