Beginnings

They came in complaining of hip pain after suffering a ground-level fall at their place of work a couple weeks ago. Back pain was also increasing. The patient was in their late-forties and had no other health history. So naturally, they were assigned to a telemetry bed for heart monitoring.

Well, they were a little anemic, too, with a hemoglobin in the 7's. A couple units of packed red blood cells fixed that.

Real problems began when the CAT scan results came up.

At The Great Muffin Factory Institute, all radiology films are digitalized, so these and written reports can be viewed anytime on any unit via a computer system. The scans for this patient revealed vertebral compression fractures and lesions, rib fractures and lesions, cracks and lesions also in the skull, pelvis, and femurs. There was a 4-centimeter opacity at their L4-L5 area and that probably accounted for the shooting pains down their leg.

I'm not radiologically very keen but even I could see that things were a real mess and the word-balloons over the doctor's heads were all flashing "mets" to me. (The link has an image of hip fracture secondary to bone metastasis from renal cell carcinoma, coincidentally.)

The residents told me that they didn't want the patient up walking around, because their lumbar disks may be invaded by tumor, and the vertebral bone was chalky and very weak. A fall, or even a spontaneous rupture could leave the patient paralysed. But the patient didn't want to hear that.

"I'm not like you," is what they told the night-shift nurse. "I believe in Jesus and there's nothing wrong with me. I feel fine."

Initially they'd refused the rib bone biopsy and MRI. Eventually they relented and the biopsy was done. We all knew what the results were going to say. But not the patient and the family.

After reviewing the MRI checklist and obtaining the patient's written consent they said just as they were at the machine that they thought they might be allergic to contrast dye. Then they said they weren't. Then they said they didn't know. They had never had an MRI before. But they heard the contrast made people get rashy. The techs sent her back. The patient just didn't know what they were thinking.

The following day the residents and radiologists convened. There was the little matter of a slightly high creatinine level; because, as it turns out, the CAT scan showed kidney lesions too so it was concluded that the cancer was originally renal cell. They really needed that MRI though, because if the mass on their L4-L5 was what they thought it was then the patient would need neurosurgery immediately.

The patient was standing in the bathroom grooming. I advised them of the risks, and they said, "there's nothing wrong with me. I have Jesus," and they walked back to bed, so tired that they were unable to get their legs up onto the bed without my help.


A few weeks ago we had an elderly woman who was lingering near death but her son was in deep denial about this. "I'm a christian and I believe my mother will get better," he said. She was eighty pounds of skin and bones, unable to eat, unable to stand, and crippled additionally by heart failure and pneumonia.

"My father was sick and he got better," he said. I asked him once where his father was, and without irony he said that he'd died. The doctors got tired of arguing with the guy and there was nothing left to be done in an acute setting anyways, so they wrote orders to transfer her to a skilled nursing facility. She died in the night before the transfer.

It's always fundamental religion that accompanies such denial about a poor prognosis.

I've never had a patient or family proclaim that "they were atheists and they wanted everything done;" indeed, the very few patients I've had over the decades who admit atheism have always, to a person, very graciously accepted news that pertained to their imminent mortality. In my experience, they seem to move through the stages of grief as naturally as they moved through life itself. Easily, anyways.

You'd think that people with a fierce belief in heaven would be looking forward to going there.

Instead they fight. Like hell, I should add.

Instead of quietly passing away at home sufficiently medicated and surrounded by family they die alone in the middle of the night, often in pain because family members insist morphine might make them die quicker.

And when that death comes it hits the family hard, like a meteor. They cry and tremble, barely able to support one another. Nobody says "they're at peace now." Nobody smiles. They just hurt. All the pain smashes into them all at once because they have refused to acknowledge the inevitable grief.

Maybe it's best just to grieve a little every day.