Tales of the Undead
This is not about a zombie apocalypse, don’t worry.
Or do worry, because it’s not about a very lighthearted subject either. It’s about Ms B.
Ms B. Is a patient in our ward. She’s not supposed to be, because I’m in a Surgery unit, and she’ll never get an operation. She’s a very quiet old lady, always smiling. She has cancer, the nasty type. In fact, she has more cancer in her body than there are Starbucks in New York, probably. She arrived last week to the Emergency Room because, basically, her cancer is so eager to take over everything it digested her stomach and now there’s a hole in it. In a very non-scientific way, it means shit is everywhere. And there’s no way we can close the hole because it’s all cancerous and dead stuff around it and she’s not really fit enough for any operation.
So she wasn’t expected to make it through the night. We took her in because palliative care was full, as it always is in this hospital, tried managing her pain, wrote everywhere that she’s “Level 4” which is a not-so-secret code for “she can do what ever she wants, go full house on pain killers and comfort measures but don’t bother her with anything else”. And expected what was to be expected
And, this past week, she’s been better and better. It’s a very common thing, actually, but no one really understands it. You have patients that have one thing to do or one relative they need to see, and usually they hang in there until what they needed to do is done. It’s not scientific but we get that, sort of. But the ones that “refuse” to go even when everything is done are still a mystery. So we do what we always do when we’re scared or lost, we joke. We say she’ll probably walk out of the hospital.
The thing is, everybody thinks about life and death as black and white. To be or not to be, we’re suddenly all existentialists when it comes to that. But the more you rub shoulders with it the more you realize it is in no way that simple.
Firstly, “death” doesn’t mean a thing.
There are as many kinds of deaths as there are moments in one’s life. There’s cerebral death, legal death, spiritual death, expected death, accidental death, and even, in those sort of cases, “diagnostic death”. Because Ms B. is an anomaly – a very charming and polite one – but an anomaly all the same: one is not normally alive and well with a purulent peritonitis on gastric perforation due to end stage metastatic esophageal cancer (yes, that’s the cute nickname for it), so she’s supposed to be not-here.
And the very limit between life and death is an utopia, if you ask me. There’s no magical on-off switch, there are vegetative states in which you don’t really know if there’s something still there, there is a whole rainbow of “more-or-less-reactive” and the number of scales we use to assess those is a testimony to how unpalpable this is. The more complicated it gets, the more instruments we try to gather…
So it’s really not “To be or not to be”, it’s more (if you’ll forgive me for a slight correction) “to be, to not really be, to be in between being and not being, to be on the verge of not-being but still hanging there, or not to be”. Even if, had he said that instead, Hamlet would have been considered crazy a lot sooner in the play.
And that is what we have to deal with, very often. And the existential wondering is just a piece of cake compared to the practical conundrums that usually come with it: In Ms B’s case, for example: feeding her normally (i.e not through the veins) would precipitate the issue, because that basically means adding bacteria to her abdomen. It would actually accelerate the process faster and with more certainty than the very controversial high dose of morphine one talks about, to “ease the pain one last time”. But it’s just feeding her, and I’m sure if I were at her place I would ask for chocolate and a glass of wine (well, I’m Swiss, what would you expect?). So do we do it? Wouldn’t it be kinder if she spent a fewer days eating what she wants than another week (or more, who knows?) waiting?
I don’t know, all I can do is try to find the time to pass by and say hi, ask her if she’s in pain or if she needs anything (to which she invariably answer “no no, everything is fine, thank you”) and wonder at those tricks life and death play with us, all the time.