Like the silent but determined minority, I have been deeply disturbed by the phrase “does not prolong life” in the WHO definition of Palliative care. I have often looked at the passiveness of the experienced and wondered whether I was supposed to emulate them. I have tried but failed spectacularly in not trying to let reason define my choices. So as I approach the final days of my first contractual faculty position, I am forced to confront the larger question staring me in the face, how receptive am I to the question of providing chemotherapy to my admitted patients?.

The opposition has been driven by ideology, as I have been taught that chemotherapy is to be provided by medical oncologists only (we do not have medical oncologists in my hospital) as well as indifference, debating the ethics of daily circus of watching referrals being given by the dozen by another team (is the purpose of admissions under palliative medicine to bypass the long queues that patients have to brave before they get evaluated by the oncologist?). So, I approached the growing realization that two my patients might be candidates with the gnawing trepidation that this would again put me in direct opposition with the so-called crypt, oops conscience keepers.

So here’s the story of those two individuals:

First, a garrulous, committed female whose life was saved inadvertently by the author (despite his allegiance to the subject’s misinterpreted philosophy), by playing a pivotal role in ensuring that a diagnosis of Interstitial lung disease was made, by virtue of a timely referral to another tertiary care cancer centre, who is stable on long term oxygen supplementation and disease modifying treatment  (including MMF, pirfenidone) at present. That she has been able to reach this place has involved an arduous fight requiring reserves of patience and due diligence on the part of all committed actors (including her, and she puts up a spirited, memorable performance each day, catching up-with her, despite my actorly ambitions is proving to be a tough task).

Second, a male with mouth cancer and a vertebral deposit exactly at the place where it could cause the most harm – the cervical vertebrae, in whom, starting chemotherapy has involved a battle – with making him wear a rigid cervical collar, engraving the goals of care deep into his psyche (plenty of no’s – no, he will not be able to walk again, no, we are not giving him treatment, no, metronomic chemotherapy may not improve survival and no, he will not be discharged against his wishes from the step-down ward) and that foes of all foes, Acinetobacter-related UTI (recently vanquished). This, aside from the palliative radiotherapy and intravenous bisphosphonate, he has already received during admission.

As, these patients, one of whom prepares herself for chemotherapy – her next battle involves visiting the hospital next door for a 2-D Echo (No, it is not available in a tertiary care hospital) and the other receives it (while admission is extended for provision of respite – one never knows when his urine drainage bag is going to leak again?), and news pops in that a committee has been formed to overlook the provision of euthanasia without mentioning the exact role of palliative care experts in it, I pause and look again at, this changing face of palliation around me and take in another breath. Am I prolonging life, or fulfilling my basic duty as a qualified specialist. Am I a crusader, or just an observant, educated, opinionated, difficult to employ individual?

Disclaimer – Every attempt has been made to safeguard the identity of patients referred to in the vignettes and any circumstances arising out of this moral treatise are completely unintended on the part of the author. The author does not intend to cause any harm to another individual’s reputation and has tried his level best to ensure that identities are fiercely protected.