17 FEBRUARY 2011

Heaven can wait

Over the last two weeks, I have been wishing my patients a happy new year cheerfully but, for a special few, it is a bittersweet greeting. I know that for them, it may be the last year they are marking.

Many patients want me to tell them how much time they have left, either because they are entirely ready or because they desperately need more time. ‘Happy New Year! How are you doing, Auntie?’ I greeted an elderly woman in her 80s as she entered my consultation room, accompanied by her maid.

‘I am well,’ replied Madam Ng. ‘When do you think it’ll be my turn to go?’ she asked earnestly, without the slightest tinge of fear in her voice. ‘You know? I’m ready to die any time.’ I responded cheekily: ‘I haven’t received any notice from above, but I promise I’ll let you know once I do.’ I first met Madam Ng in 2001 when she was hospitalised under the care of another oncologist.

Her brother came by to see me first and asked if I would be willing to take over her management. It is not unusual for cancer patients to transfer care from one oncologist to another.

Due to the seriousness of the illness, patients are often desperate when things are not going their way – when the disease is not responding well to treatment or when complications arise. As a general courtesy to one another, for patients who are hospitalised, doctors always ask the patient or family to speak to the current primary physician to initiate the transfer of care.

Whether the physician likes it or not, he must always agree when asked. It is the patient’s prerogative to choose his medical attendants. Madam Ng had stage 4 lung cancer and she was in a coma when I first met her. She had been given chemotherapy just before she lapsed into unconsciousness.

The computed tomography scan of the brain showed no significant abnormalities – bleeding, infarction or metastatic cancer. As there was no structural injury seen on the scans, the most likely cause of her coma was metabolic disturbance like low sodium concentration in the blood.

Salt is very important to the human body. Whenever sodium levels drop, patients would often feel tired and lethargic. If the levels become very low, one can become confused and eventually lapse into a coma. With careful correction of the imbalance of her electrolytes (which are compounds such as sodium that dissociate into ions in the blood) and good nursing care, Madam Ng made a slow but steady recovery.

Frightened by the mere whisper of the word chemotherapy, she had been given only targeted treatment over the past 10 years. Her disease has remained in remission all these years with maintenance treatment in the form of pills and injections. She suffers more from the general ailments of a geriatric patient – degenerating joints, impaired kidney function and failing hearing – than from her cancer.

So, I was able to wave her off with a genuine smile in my heart as well as on my face. But it is a different story for Veronica, who is in her mid-50s and also has stage 4 lung cancer. She came to see me in May last year, when she was diagnosed with a cancer relapse. Despite having had half of her left lung removed, the cancer returned with a vengeance. When she came, she had shortness of breath because her left chest cavity was flooded with cancerous fluid.

Despite drainage, she remained breathless as the cancer had infiltrated the lymphatic vessels in both lungs – a condition called lymphangitis carcinomatosis. One of her cancer markers was more than 5,000 times higher than normal, while another marker was more than 3,500 times the normal level. ‘At what levels will I die?’ she asked me. These markers are mere measurements of certain proteins produced by some cancer cells. These proteins are not ‘poisonous’ and are not harmful.

However, they are often a very good measure of how bad the cancer is and how well it is responding to treatment. Veronica has been on chemotherapy since we first met. With each chemotherapy cycle, her cancer markers have dropped. Her scans have shown marked regression of the tumours. More importantly, she is feeling significantly better and is able to resume her normal daily activities. While things are getting better, it is difficult to predict the course which the disease will run.

Furthermore, there is a great deal of uncertainty in predicting outcomes for the particular type of cancer, called non-small cell lung cancer, that both women have. One patient, at the tail of her life, is rich with experience and at peace with its ending. She recovered from a coma and is in good health after many years, with the disease well-controlled. Another is in her prime, eager to do more. But I do not know if she will have the time. With help from science and machines, I can manage their disease, read the insides of their bodies, tell them the very chemical birthmark of their cancers.

But when it comes to telling them when they will die, I am at a loss. All I can do is hope and pray – for a peaceful exit for the first and for more time for the other. The last leaf drops when it wants. We need to remember that the measure of our lives is not taken on the day it ends, but from all those that have gone before.

This article first appeared in "Mind Your Body", a Straits Times Supplement.