Final Acts: Death, Dying, and the Choices We Make

Elegy for an Optimist

123 VVVVVVVVVVV Elegy for an Optimist MIMI SCHWARTZ “So Doc, when do we start?” my father-in-law said, hunched over from stomach cramps. My husband and I refrained from asking the oncologist, who had just prescribed a powerful, six-cycle dose of chemotherapy, a lot of what-if questions. How could we, after being warned that if we did nothing, “your father will starve to death, and that isn’t a pretty sight!” Besides, this expert assured us that even at age eighty-four there were one-in-five odds for a cure. Charlie could be alive for his granddaughter’s wedding in six months, we told each other as we left his room. He was released from the hospital on day six, and everyone said he took the chemotherapy better than anyone they’d seen. No hair loss, no vomiting, the head nurse said, even though his blood pressure dropped on the morning of his checkout and his stomach cramps returned as soon as they fed him oatmeal. Constipation, they said. He’ll be fine. Three days later we half-carried him to the emergency room of our local hospital. He hadn’t been able to eat, could barely drink, and had been up for three nights with pain. But eight hours after being hooked up to an IV (his first nourishment in days) and getting fresh blood from a transfusion, Charlie was talking about going home to his apartment the next week. He would hire a nurse’s aide for a few hours a day, if he needed one. My husband and I said, “Let’s just see!” We kept saying it, even after they inserted a permanent catheter into Charlie’s vein for easier transfusions and for a total liquid feeding that bypassed his stomach. We said it even after we asked the young resident how soon the first cycle of chemotherapy would shrink the tumor blocking his stomach. “Oh, that might take another five cycles,” he said, very upbeat. “We have to build him up first before we can start again.” I have heard senior citizens complain about being written off by the medical profession, but not Charlie. With his gentle charm and solid insurance coverage from fifty years as a union man, he had everyone, from specialist to orderly, backing him 150 percent. His optimism was theirs as they took him daily for X-rays, CAT scans, MUGA scans, physical therapy, and endless tests. “You’re doing great,” they said as his blood pressure sank, his heartbeat became erratic, and he was moved to intensive care. We did mention a living will then, but Charlie didn’t want to sign one. “One-in-five odds are good, remember?” He smiled. “It’s his choice,” my husband kept saying, and I kept quiet, just as I had when my high school friend had brain cancer. Her family, desperate for a promising treatment, had asked me to ask my oncologist friend to suggest which of three experimental research trials to enter. After hearing the diagnosis , my oncologist, who practiced 1,000 miles away, said, “It doesn’t matter what they try, she’ll be dead in eight months.” And she was—but not before having undergone eight months of experimental drugs given by doctorresearchers who kept saying she was doing great. According to American Medical Association guidelines, doctors should elicit “informed consent,” based on a patient’s choice after discussion of “alternative treatments and consequences of treatment, including the consequence of no treatment.” But is it choice when your doctor gives you onein -five odds that contradict those, outside your personal medical loop, who say you haven’t a chance? Is it choice when these odds are based on the whole population, and you are an eighty-four-year-old with a history of heart attacks? In a study of 917 cancer patients that I read in the Journal of the American Medical Association, most patients are overly optimistic and, like Charlie, choose aggressive, painful treatment that does not extend life, only discomfort. Their doctors, on the other hand, are highly accurate in prognosis ; more often than not, they guess right about what to expect. True, it is not easy to convey accuracy along with hope; and it is not easy to get patients to hear both parts of the message at once. But it is easy to avoid scare tactics like “starving to death is not a pretty sight.” (We learned, subsequently, that people dying...