28 JUNE 2012

A human touch

The upcoming Lee Kong Chian School of Medicine at the Nanyang Technological University aims to train doctors who are both competent and compassionate, its senior vice-dean, Professor Martyn Partridge, has said. I fully agree that it is important for a doctor to be compassionate to be good. Compassion is not just a warm, fuzzy feeling sprung from the desire to do good.

Equally important is the doctor’s skill in communicating to the patient that the doctor has his well-being at heart. This, of course, is easier said than done. Madam Low, a 50-year-old woman, first presented with yellowing of her eyes and dark tea-coloured urine. She was admitted to hospital and underwent a series of tests. These confirmed she had stage 4 pancreatic cancer which had spread to the liver.

The prognosis for such patients is very poor. In most medical literature, the average life-span reported is between three and six months. The doctors who first saw her understood the grim odds. Although they were not oncologists, they decided that she should be spared the ravages of chemotherapy as the disease was clearly incurable. They cannot be faulted for their decision. It was a judgment call and they felt that no active treatment was the best option for her.

The patient and her family related to me how the bad news had been conveyed to them. It was sad, yet a little funny, when they related the conversation verbatim. While describing the aggressive nature of the cancer, the senior doctor had said: ‘Very fast one, you.’ He had added: ‘Can go home today. Do what you want and be happy.’

Following his cue, the junior doctor had added: ‘Hospital food is not nice to eat. You can go home and eat the food you like.’ Seven months from that day, she is on chemotherapy and responding well and can now find humour in the grim message. However, at that time, those well-meaning words were very hurtful as they meant there was no glimmer of hope. Many such patients end up seeking second, third and more opinions.

Some turn to doctors and others to practitioners of traditional Chinese medicine and alternative medicine. I have another patient with pancreatic cancer, Mr Ong, 61, who presented with abdominal pain and severe weight loss. By the time he saw me, he was cachexic, or extremely thin, and wheelchair-bound.

The positron emission tomography (PET) scan showed a cancer of the pancreas with extensive metastases (spread) to the liver. The liver function was so severely compromised that his protein level was very low. This resulted in water retention and swelling of his abdomen and legs.

His medical condition was a great deal more serious than Madam Low’s as his abdomen was bloated to the size of that of a full-term pregnant woman while his legs were also markedly swollen. I explained the seriousness of his condition and the options of supportive care alone and palliative chemotherapy.

As his physical condition was poor, I highlighted the possibility that the chemotherapy could expedite his demise. A man of few words, he said: ‘Fight lah.’ After the first dose of chemotherapy, he experienced diarrhoea and ended up in another hospital. The consultant in the ward advised him to stop treatment and suggested hospice care.

Unconvinced, Mr Ong came back to see me. I explained to him that the consultant was not wrong. I reiterated the pros and cons, and the benefits and hazards of continuing treatment. The decision of whether to get treatment was left to how badly he wanted to try and prolong his life and what risks he was prepared to undertake.

After listening to me for nearly an hour, he said again: ‘What to do? Sick must fight lah.’ Eight weeks have since passed. He is feeling better and the water retention has largely subsided. The jaundice has also faded. His level of CEA, a cancer marker, dropped from 1,500 to 350 units.

It is premature to pop the champagne but the early indicators suggest that Mr Ong is responding well to treatment. The outcome could have turned out very differently. His disease could have progressed despite treatment and he may have regretted his decision to be treated.

The consultant knew that there was no cure for stage 4 pancreatic cancer and felt that keeping him comfortable was more important than fighting the cancer. I understood perfectly the consultant’s genuine concerns about the dangers of chemotherapy. Unfortunately, they were misinterpreted by the patient.

To him, the doctor did not care and was just ‘waiting for him to die’. Medicine is, most of the time, about the application of hard, objective scientific knowledge. Such things as compassion and communication skills are often thought to be ‘softer skills’ acquired on the job and as optional extras. But to me, they are at the heart of medicine.

Medicine tells us what options are open, what advice we must give, but, in the end, we must have enough compassion to take the time to explain these clearly and well to the patient and respect him enough to let him decide what to do with his life. This article first appeared in "Mind Your Body", a Straits Times Supplement.

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