Eaten away

When he first walked onto my ward, red-faced and nostrils flaring, making his way slowly but determinedly down the corridor, I had assumed he was a irate relative coming to pick a bone with me about one of the patients under my care.

As he reached the nurses' station, he demanded to speak to me. His chin was quivering with exhaustion, his voice was hoarse, his words were wheezy, the tendons in his neck stretched and strained. Then, I knew how sick he was.

Earlier that day, he had gone for a chest radiograph and a CT scan before arriving on my ward, the results of which showed a several large tumours sitting on each lung, which was also half filled with fluid. He had been shown the scans and X-ray films, and had been told by the consultant that it was likely to be lung cancer.

"But, I don't believe him!" he declared, "It all sounds like a load of hogwash and I'm not buying it. So, I don't want any more of these rubbish tests." He started to gasp for breath and I put the oxygen mask over his face.

I explained to him that we needed to get a biopsy sample of the tumours to see what they were made of. The sample is obtained via bronchoscopy, which means using a telescopic camera to look into the breathing tubes of the lungs. This way, we could find out what the best treatment for him would be.

"No! No more tests. I don't think it's cancer, and I don't believe what you say about it."

I tried talking to him about using very fine needles to suck out some of the fluid that had been building up inside his lungs - we could send some of it to be looked at under the microscope, and he would be able to breathe better without so much fluid sitting on his chest.

"Don't you understand? I said no more tests. I mean it. No more tests."

I pointed out to him that he was already having difficulty breathing, and then there was not much we could do except give him simple treatments to support his lungs and prevent infection. Without a tissue diagnosis, we would not be able to give chemotherapy. Radiotherapy could be an option, if he would accept that.

"Radiotherapy? What for? I don't want it. I don't have cancer, I don't care what you say, I don't want it. Let me go home."

I put on my sternest doctor voice and told him that if he could manage without the oxygen and look after himself, then he could go home today. If he could not, then he would have to stay with us until we had his home outfitted with all he would need. This could take several weeks. He grew quiet.

Later that afternoon, his daughter walked onto the ward, red-faced and nostrils flaring, making her way determinedly down the corridor to see me. Irate, she demanded that we carry on with the tests and start the treatments necessary.

I asked her if she had spoken to her father about it. She shook her head, angrily. "He's a stubborn man, and won't listen to me anyway."

Gently, I explained to her that we cannot force her father to undergo invasive testing or arrange treatments for him that he will not accept.

She stared at me, eyes wide with horror. "Are you just going to let him die?"

I looked at her levelly and reminded her that there is no cure for cancer, especially one that seems to be at an advanced stage - all the measures we would have are either for holding off the inevitable so that affairs can be put in order, or for reducing discomfort. Her father had chosen to fight his illness on his own with as little intervention as possible, and we had to respect that. He had chosen to let nature take its course and I had to respect his choice.

Yes, I am letting him die.

There was fire in her eyes and I knew that she hated me then.

Day after day, I would talk to Mr Stubborn in the morning, and try to persuade him to undergo tests and receive treatment. He would refuse. In the afternoons, his daughter would visit him and try to persuade him to accept the tests. He would shout at her and tell her to get out. She would leave the room, then rail at me for my ineptitude. I began to think I would burst into flames whenever she looked at me with such hatred.

Soon, Mr Stubborn was too unwell to undergo any tests, even if he had agreed to them. By then, he had lost his robust figure, his weight falling off him as the growing cancer leeched away more and more of his energy. His bones showed through his skin, his eyes were filmy and dull, his lips puckered like a prune. He occasionally refused medications. He only accepted what could be delivered through his oxygen mask, and perhaps the occasional paracetamol for pain. He would not touch the steroids or the antibiotics. He would not allow us to give him morphine.

Looking at him, I remembered a piece of installation art from the Museum of Contemporary Art in Chicago. It was by a young man called Felix Gonzalez-Torres. His work was a pile of candies, in shiny metallic gold and silver wrappers, laying in a corner of the room. The weight of the pile was equivalent to the weight of the artist when he had first been diagnosed with AIDS. Visitors were encouraged to take a piece of candy from the spill. My piece was a chocolate covered toffee. Slowly, the sweet stack diminished in size, slowly eaten away, until nothing was left.

One afternoon, his daughter sat down with me for another session of "You Doctors Are So Incompetent". I sat in silence for a while after she finished speaking. Then, I said quietly, "It's very frustrating for me to watch him deteriorate like this and not be able to do anything to help him. I cannot imagine what you are going through, being his daughter."

The fire in her eyes spluttered and died. She burst into tears and wept uncontrollably, and I wept with her. She did not hate me, she did not hate him for being so proud and she did not hate herself, either.

Afterwards, when she visited her father, she would sit in his room, in silence. He did not shout at her or tell her to leave. Instead, he would talk about the weather, complain about hospital food and talk about his grandchildren. She told inappropriate jokes about Irishmen, popes and rabbis, and ducks walking into bars.

He died soon after.