29 NOVEMBER 2012

A doctor's dilemma

Some years ago, I remember my mother asking me: "Peng Tiam, when patients die, have you been scolded by their relatives?"

My first reaction was: "Of course! What do you think?" Facing and handling death are so much a part of my work that I have come to accept all the different reactions - the deep appreciation and gratitude as well as the verbal abuse and threats.

And then I thought: "They don't scold me half as much as I scold myself." Mr Ho was a 63-year-old factory supervisor who saw me in August because he had liver cancer. He was first diagnosed, after feeling abdominal pain, with liver cancer a year prior to seeing me. He had surgery which successfully removed one of the two liver tumours, which had ruptured. The other tumour could not be removed. The cancer grew and gradually spread to almost the entire liver. He was treated with radioactive beads, which were injected into the liver, as well as with a novel oral cancer drug called sorafenib (Nexavar).

Despite treatment, the disease continued to get worse and his physical condition deteriorated. No other treatment options were offered. When I first saw him, he came into my office in a wheelchair pushed by his family. He weighed 54kg, but his actual weight was probably much less, as much of the weight was due to water retention in both his legs and in the abdominal cavity.

His liver was enlarged. I explained to him the seriousness of his cancer. The cancer had replaced almost the entire liver and was distorting and stretching the liver surface. He had two options: to leave the cancer alone and focus on comfort care to minimise his symptoms; or to have palliative chemotherapy, which would at best control the disease and buy him some time. As the chemotherapy would be injected via his blood vessels directly into the liver (intra-arterial chemotherapy), there was a risk of liver failure.

I quoted a 10 per cent risk that the liver tumour could rupture and he could perish instantly. The risk of a rupture of the liver tumour also exists without treatment, as was the case when he first saw the doctors for his abdominal pain. Five days after our initial consultation, Mr Ho returned with the decision to go ahead with the intra-arterial chemotherapy. He was admitted on the same day and the treatment proceeded uneventfully.

He felt better after the procedure and was discharged from the hospital a couple of days later.

Two days after discharge, Mr Ho was readmitted with low blood pressure and severe anaemia (lack of oxygen-carrying red blood cells). Investigations confirmed that his liver tumour had indeed ruptured and he was having massive internal bleeding. We pumped in packets of blood and other blood products, but we were not able to save him. I was deeply affected by his death. I kept asking myself if I should even have offered him treatment, considering that his cancer was so advanced.

He might have lived longer, suffered less, spent more time with his family if I had stayed my hand. I made a mistake, I told myself. My only consolation was that up to 60 per cent of patients with liver cancer do respond favourably to intra-arterial chemotherapy, and I clung on to that statistic in the days after Mr Ho died. This also brings to mind Mr Lim, a 46-year-old man who had been diagnosed with inoperable liver cancer in October 2010.

Like Mr Ho, he was treated with sorafenib but the cancer did not respond. He had been seen by several doctors and had been told that his only option would be a liver transplant. When we first met in April last year, his liver was so huge that his abdomen was bloated like that of a pregnant woman at mid-term. After six rounds of intra-arterial chemotherapy, he responded marvellously. The cancer regressed significantly and has remained stable since.

Eighteen months have passed and he has remained well and fully functional. As I was planning to write about these two patients, I called to ask for permission to share their stories. Getting consent from Mr Lim was no problem. He wanted his story to be told, to encourage others like him with liver cancer not to give up. But it was with some trepidation that I called Mrs Ho. I said a little prayer before I dialled her number.

I did not get scolded or berated. She was gracious and kind. She recalled that it was Mr Ho's decision to go ahead with treatment. She understood that I tried my best and agreed to his story being told. Each day, doctors are placed in a position where we are called upon to make clinical judgments on how to treat each patient. But the results of such judgments are sometimes as much a matter of chance as they are of science.

When we fail - knowing the odds of success, the goodness of our intentions, and even the grace of our patients and their relatives - we still cannot silence the voice inside asking: "What if?" This article first appeared in "Mind Your Body", a Straits Times Supplement.