A friend who is also an oncology nurse told me a particularly harrowing story about a patient, a man in his 60s, who was admitted to her floor with a new cancer diagnosis.
Treatment would involve a month of hospitalization and surgery to insert a central line in his chest to administer the chemotherapy. The patient was reluctant to go through with it, but the night before the operation, his daughter talked him into it.
The next morning, however, he balked. He refused to go to the operating room and said he was refusing treatment. His wish, he said, was to go home, sit on his porch, drink beer and smoke cigarettes.
It wouldn't be my choice, but I also can understand why a treatment plan involving weeks in the hospital and multiple infusions of potentially lifesaving, but also toxic, drugs would be difficult to accept, even if death was the alternative.
The doctor on the case, an oncologist in training, didn't see it that way and told the patient how he felt about the decision to refuse treatment. "If you were my father," he said, "I'd be disappointed in you."
My friend, the nurse, wanted the patient to answer, "And if I were your father I'd be disappointed in you for not supporting my decision." But the patient just said that he wanted to be referred to hospice and be given narcotics to control the pain he knew would come. He wanted to be in his home enjoying life his way for the last few months he would have.
At one point the doctor asked my friend to step out of the room, and she did, thinking he wanted to speak to her privately in the hall. He actually just wanted her to leave so that he could talk to the patient alone. My friend refused. "I'm the patient advocate," she told him.
Back and forth they went, until finally the doctor accepted that he was not going to change the patient's mind and that he couldn't bully the patient into accepting treatment.
But the doctor did refuse to refer the patient to hospice. The medical team listed the patient as leaving A.M.A. — against medical advice — and said a hospice referral posed too great a liability risk in that case.
My friend said work had never made her quite as angry as she was that day. Together she and the nurse who arranges discharges did an end run around the oncologist and had the patient's primary care doctor set up the hospice referral, giving the patient access to the pain medications and end of life treatments he would need.
In the book "How We Die," the surgeon Dr. Sherwin Nuland offers an explanation for the oncologist's behavior. Dr. Nuland argues that over the past 20 years we have made so much progress in treating cancer that doctors feel they should err "on the side of doing more rather than less."
"The very success of his esoteric therapeutics," Dr. Nuland writes, "too often leads the physician to believe he can do what is beyond his doing and save those who, left to their own unhindered judgment, would choose not to be subjected to his saving."
Americans admire people who fight, who struggle to the bitter end. We root for the underdog. But maybe this patient didn't need anyone's admiration or cheers; maybe he just wanted to go out his own quiet way.
Such people often get labeled cowards, failures or, as the doctor suggested, disappointments, but how many of us could look a cancer diagnosis in the face and say, "I do not want your hospital and your needles and your drugs, even if it means I will die?"
I feel certain I could not, even that I would not. It wouldn't be because I'm strong where this patient was weak, but only because I would be willing to trade the challenges of treatment for the possibility of more life.
