That’s right, anything that you swallow will probably come back up again. It’s a mechanical obstruction and our medications won’t be able to keep it unblocked.
There’s no other treatments?
We could try steroids to see if it could lessen the cancer swelling, to see if it would loosen up the blockage. It may not work, and even if it does work it will only work for a short time. And there can be side effects. Some people become more agitated, it would worsen your immune system so it would be easier for you to get infections.
Hmmm. I need to think about it
That’s fine, I wasn’t expecting an answer right now. We will keep checking in with you, we want to make sure we do right by you. When you are very unwell the body had difficulty keeping things in balance. For example physical balance can be affected and it mean you are at greater risk of falling. That’s why we’ve been nagging you about not walking by yourself.
Nod.
I know you want to stay as independent as possible but we need to keep you safe. I don’t want you breaking a bone, you’ve got enough going on already.
Sigh.
The illness can also affect your mind balance too, you’ve probably had some trouble remembering things.
My memory has been bad for months.
And overnight you were a bit confused.
Yeah, I wasn’t sure where I was.
The strain and drain on your body from the cancer is causing it all. I know you’re trying your best to be yourself, but it’s becoming harder and harder. Things are becoming a struggle for you.
Nod.
I don’t want you to struggle. Please let us help you with some things. To try and free up some energy for you. So you can spend time with your friends and family.
They keep encouraging me to do stuff, but I’m not sure I feel up to it.
Listen to your body, if you feel up to it, go for it. If you don’t it’s okay to have a rest.
Nod.
Okay we’re going to work on your nausea today, and we’ll check in with you again tomorrow morning about the steroids. I just want you to know that no matter what happens we’ll keep on trying to make you more comfortable. There might come a point where you aren’t able to speak for yourself and I just want you to know that we will act in your best interests. We will always try to make you more comfortable.
Thanks Doctor.
You’re welcome. We’ll see you later. Please let us know if you need anything else.
I had been meaning to write the following blogpost for the past weeks and decided to do it today. I was also inspired by a LinkedIn post from a writing community co-member to try out ChatGPT the AI Author bot from https://chat.openai.com/chat. Here’s a comparison of what I wrote in one 25 minute Pomodoro and what ChatGPT wrote in 25 seconds.
A too late early Christmas Present – by James Jap – 25 minutes
Communication had become difficult and was another thing that cancer had robbed her of. She had lost her voice and had to write words down in order to communicate.
She had tried various methods from good old paper and pen, and had settled on a whiteboard and a set of markers.
This worked well enough but due to her condition at times the whiteboard would become wet and then the markers could not write clearly. Waiting for the marker and the board to dry off meant a delay in communication.
Simple gestures could be made in an attempt at impromptu sign language but it could not convey what she wanted to say.
She could mouth words and some people were better than others at reading lips but this was not something that could be counted on.
I had enjoyed getting to know her and we had exchanged witty banter between ourselves.
I would say something.
She would write something funny in response.
She made fun of my hairstyle. She talked about my bathroom habits and my general appearance.
I talked about referring her to our physiotherapist to help with mobility and to help with clearing chest secretions.
She wrote, “I don’t want them thumping me.”
I replied that I would not let our Physio-terrorist do that to her.
She raised her eyebrows in quizzical fashion.
Despite severe pain she never lost her sense of humour.
Christmas was coming up and I wanted to surprise her.
I had seen some electronic notepads in one of those stores that used to sell books, I think people in the past called them bookstores. I made a plan to buy one for my patient.
I thought that having something with an LED screen that could be written onto with a stylus could be handy for her, and it could be erased with the press of a button.
I went out to search for this little notepad but not being an experienced shopper I made a number of mistakes.
I knew there was a bookshop nearby in the local mall, I headed out to the mall, and then could not find the bookshop. In the three years since I had been to the mall, the bookshop had closed down.
I looked for other bookshops but then smartened up and looked up where I could buy the electronic notepad from a local shop.
I found it and proceeded to the shop, I asked three people for their assistance but no-one was able to help me.
The fourth person at the customer service desk confirmed my worst fears, they were out of stock. But I could go across town to their other branch which had stock.
Off I went with my phone’s battery running out, making GPS a soon to be unavailable feature. For some reason traffic is busier in the weeks before Christmas. Shops are also busier and people seem more stressed and less friendly.
I arrived at the other store branch and again asked for assistance showing the store worker a picture of what I wanted to buy. He was helpful and led me right to a shelf which contained non-electronic clipboards.
On his second attempt we found the electronic notepad I had been searching for. Success at last. I tested it out, I could write on it easily with the supplied stylus and it erased with the touch of a button.
I presented the electronic notepad as an early Christmas present to my patient, and showed her how to use it. She thanked me in writing and I said I would catch up with her the next day.
The next morning I went to see the patient but the electronic notepad was not in sight. The old whiteboard was there.
Had my early Christmas present come to late to be of use?
My patient was much slower to respond to any questions, and even had greater difficulty in writing. She had deteriorated overnight and was not her usual self. Her usual quick wit had slowed down markedly and she was not as clear in her mind as she had been just yesterday.
A lot can change in a day in a palliative care setting and here was a clear example of the change, she had changed cognitively overnight and was not longer able to use the electronic notepad.
I worried that this meant that she might only have a short time left to live, and this was conveyed to my patient and her family.
A too late early Christmas present – by ChatGPT Dec 15 Version – 25 seconds
It was the first week of December and Lucy was already feeling the holiday cheer. She had always loved Christmas and the excitement of gift-giving and receiving.
This year, she had decided to surprise her husband with an early Christmas present. She had found the perfect gift, a new set of golf clubs that he had been wanting for a long time. She wrapped it up carefully and placed it under the tree, planning to give it to him on the following Saturday.
However, on Wednesday night, Lucy’s husband came home with a big grin on his face. He had received an early Christmas present from his boss at work – the exact same set of golf clubs that Lucy had bought for him.
Lucy was initially disappointed, but she couldn’t stay mad at her husband’s excitement. They decided to return the duplicate gift and use the money towards a family vacation instead.
In the end, it turned out to be a blessing in disguise. The family enjoyed a wonderful vacation together, creating memories that they would cherish for a lifetime. And when they returned home, Lucy’s husband was still grateful for the thought and effort that she had put into her early Christmas present.
“Good morning, I’m the specialist here. What’s your name? This is your daughter. How old is she?”
“She’s eight.”
“You’ve all had a rough night.”
“Yeah, every time they turn him he has bad pain.”
“There’s been a lot of changes over a short time.”
“Things have been happening too fast over the last weeks.”
“We need to make some changes to make him more comfortable. It would be better for him to have a catheter, then he won’t get wet and we won’t need to change his pads so often.”
“Okay, let’s do it. His breathing has changed, is it a sign that things are getting worse?”
“Yes, everything is getting worse. His body is so unwell that it can’t control his breathing anymore. His breathing gets quicker, then it slows down, and then there are gaps. As he becomes more unwell the gaps become longer and longer. His hands and feet will start to feel cold as his circulation worsens.”
“How much time do you think is left? Should I call the rest of the family in? They visited last night.”
“It might just be hours to short days left, but he could have much less time if the changes continue happening faster. He could go at any time. It’s a good idea to call the rest of the family in.”
“We’re going to change the medications to control the pain better. Since I’m already gowned up I’ll put in the catheter now. I’ll ask my team to bring the equipment in.”
“Okay, I’m going to step out to make some phone calls.”
“Hey man, I’m going to pop in a catheter to catch your urine, it’ll keep you nice and dry. Then we won’t have to change you as much which won’t be as painful. We’ll keep a close eye on your wife and daughter. Your daughter painted something nice for you, looks like a fairy with a magic wand with a star on it, in purple. The words say I love you Dad.”
“I’m just going to check the pulse on your neck. Hmm, I can’t find it. I’m going to listen to your heart and lungs now. I need to shine a light in your eye. Same on the other side.”
“What’s happened?”
“I’m very sorry for your loss.”
“Mummy, why isn’t Daddy breathing?”
“I’m sorry your Dad has died. He was trying his best to hold on for you, but the illness has been too much for him to handle. Now he doesn’t have any pain and he is heading up to heaven. He’ll still be keeping an eye on you and will be able to hear what you say to him.”
“You’re working hard to breathe. You’re having to shrug your shoulders up.”
“Yeah, Mum’s like that in the morning. She’s better in the afternoon.”
“I’m seeing quite a difference in Mum since I last saw you both a few days ago. I’m worried about her. I think we need to put a hold on the discharge plan. We need to calm things down first.”
“Okay.”
“Are you okay staying with us a bit longer?”
Nod. “I. Love. This. Place.”
“We’ll see how you go, one day at a time. If things become stable then we can talk about going home again. If things get worse, it might be better to stay here.”
Nod.
“No matter what happens we want to get you more comfortable, and let your daughter have a bit more rest.”
She hadn’t trusted her daughters and wasn’t keen on medications in general. She had tried to hide how unwell she was. They had wanted to help her but she had felt so unwell that she couldn’t accept their help. Everything had hurt, her head, her skin, even her hair. Nausea was her constant companion, and vomiting was the guest who kept overstaying their welcome. She didn’t want to go to the hospital, she said she would give hospice a go.
“I feel heaps better today.”
“What’s going on?”
“My pain is gone, I don’t feel sick anymore since the elderly doctor started the medicines yesterday.”
“That’s good. Did you have some breakfast?”
“Yeah, I had some porridge, but they didn’t cook it the way I like it. There was brown sugar but it wasn’t quite right.”
“You managed to keep it down.”
“Yeah, first time in a while.”
“Good. What do you think is going on? What did your doctors tell you?”
“I like my cancer doctor, he’s a Pakeha but married to a Māori. He told me like it was.”
“Straight up?”
“Yeah, none of that bullshit the others had used. He was honest, and let me know what was going on.”
“You’re not going to get any bullshit here. What did he say?”
“The cancer has spread from my lungs, has gone to my head. There aren’t any treatments left for me.”
“What do you think has been going on lately to make you feel so bad?”
“Probably the cancer getting worse.”
“Yeah, I think the cancer in the brain has grown bigger. It’s giving you headaches, making you feel sick and vomit. Has your thinking been not so clear?”
“Yeah, it hasn’t been right since the radiotherapy and the chemo. If anyone asked me if they should have the treatment for cancer, I’d tell them not to.”
“It hasn’t helped?”
“No, I feel so much worse.”
“You gave it a go. I need to check with you about what you want. There’s a treatment that might help you, but it probably would only work for a short time. You could either try it or not. It’s up to you and the whānau.”
“Hmm, I’m not sure. What do my children think?”
“We want you to try mum.”
“Okay, I’ll try it. Thanks for being honest with me.”
“No worries. We’ll give it a good go, and see what happens. E noho ra.”
“Do you all understand what is going on? Do you know what is causing the gut blockage?”
“Is it to do with the illness? The cancer?”
“Yes, that’s right. Cancer which goes to the tummy can slow down the gut, that’s why the poos had slowed down. If there is enough cancer there it can cause a blockage, which is like a blocked pipe. Whatever goes down the pipe can’t pass through the blockage and then comes back up as vomit.”
“Can you pass another pipe through?”
“If there was only one blockage they could’ve tried to do that in the hospital, but the problem is there is more than one blockage and the re-piping wouldn’t work.”
“Could you give IV fluids, would that help?”
“IV fluids is done all the time for patients with bowel blockage in hospitals. What we have found is that the fluids can actually make things worse for the person. The fluid through the vein will lead to more gut juices being made which would increase the vomiting. Also when you are so unwell the body can’t handle the extra fluid. It ends up causing painful swelling and might make the breathing worse. We don’t want to make things worse. If I thought that giving fluids would help I would do so, but I think it would make things harder, so I won’t be doing that.”
“The cancer can cause swelling right? Is there anything you can do for that?”
“Cancer can cause swelling around it which could be leading to the blockage. We can try a steroid medication to see if it would help. We’d give it three days’ worth to see if it helped, or not. Would you like to try?”
“Yeah, I’d like to try that.”
“Okay, we’ll try that. We’ll also try another medication to dry up the gut juices, to see if it would make you vomit less.”
“You all have been asking good questions. Do you have any more questions?”
“No doctor, you’ve answered them all. Thank you.”
“You’re welcome. We’ll take things one day at a time, and we’ll always keep trying to make you comfortable.”
In the last days of her life, she was visited by close friends and family members. She conversed with them and still shared her sense of humour with them. To some of her oldest friends, she said her final goodbyes.
One of her best friends asked me if it would be okay for her to have some champagne. I said I would allow it but she wasn’t allowed to drink alone. He went off to buy some. It had to be Tattinger Champagne, nothing else would do. I said she could eat whatever she felt like. A question was asked about cigarettes and again I had no objections. She was dying and she could do whatever she liked that would bring her some pleasure and normality.
“How can you tell that time is short?”
“She’s been deteriorating every day. She has become unclear in her thinking and is needing to sleep more. These are all signs that death is coming soon.”
“How long do you think she has got left?”
“A few days ago we thought she might only have days to weeks left to live. Now I think she only has hours to days left. She could die at any time.”
“Who do you think can come and visit her.”
“I’d recommend only immediate family only and her closest friends. Whomever she wants to see.”
“Will you let our brother know?”
“Sure, we’ll make contact with him.”
The next day four members of the hospice clinical team painted their nails yellow and orange to match their patient’s fingernails. When she woke up she was shown the photos and she was able to enjoy the yellow-clad doctor’s finger and toenails which were all highlighted in bright yellow. The nails gave her and the family something to smile and laugh about in between the tears.
The next morning the Polish team, who were not from Poland, were about to go into the room when the nurse came out to ask the family to come in urgently.
“She’s about to take her last breath.”
The clinicians made way for the family.
She died with the voices of her family telling her how much they loved her.
palliverse.com 