As a young doctor, death feels like the enemy. I remember another patient: a delirious elderly woman in a high-level care nursing home who was urgently admitted under our surgical team with a strangulated hernia. She was operated on successfully, but it was later identified that her wishes (outlined in an advanced care plan) stated that she did not want any lifesaving invasive treatments and instead would opt for comfort care.

Day 1 post-op, she regained consciousness in the ICU. Day 2 post-op, she was transferred back to our ward and things seemed to be going magnificently. Day 3 post-op, she was reporting significant and worsening abdominal pain and said she could not open her bowels or pass any wind. Day 4 post-op, with nasogastric tube inserted, and ‘nil by mouth’ orders enforced on her, she was marched to the radiology department for a barium enema study to determine if she had a bowel obstruction – that is, a significant blockage of the bowel and a complication of her ‘life-saving’ surgery. Day 5 post-op, the results showed no signs of obstruction, but the pain and the feeling of constipation remained. Her abdomen was distended and bloated, skin stretched as tight as a drum, and we had no idea why. Day 6 post-op, despite increasing doses of morphine and other analgesia as well as aperients and laxatives, her pain and discomfort continued to rise, and her delirium had returned. Day 7 post-op, X-rays, CT scans and blood tests were all requested. The nasogastric tube returned and a strict fluid restriction was imposed. Still she continued to deteriorate, mind and body. Her family were distressed. The nursing staff were distressed. The surgeons and the registrars were busy with newer admissions, more surgeries and teetering on the edge of burn-out.

Day 8, and I was being told by the nurses that I had to call the palliative care team to review the patient. I could see her suffering and I could tell that we were not winning the battle we found ourselves in. I also knew the patient’s wishes. But still, palliation was a dirty word. It was admitting defeat and it felt unfair. I spoke with my registrar, I told him that the nurses recommended we liase with the palliative care team. He rebuked the idea, he reminded me that we had found nothing wrong with her and we shouldn’t give up. Day 9 post-op, on our morning ward round, she was half conscious with labored breathing. The surgeon and registrar wanted more tests, a discussion with the ICU on her condition and a cardiology consult. After the ward round, the nurses pleaded with me again to call the palliative care team. I tried to delicately raise the issue again with my registrar, and this time, he angrily said ‘do what you want’. Do what I want? Those words stung. This was hardly what I wanted. Calling the palliative team felt like giving up on our patient; it felt like proclaiming a death sentence. But not calling them was to allow further testing, poking, prodding and prolonging what appeared to be an agonising existence.

I called the palliative care team. They came on the same day. With well-rehearsed sadness they concurred with the need for palliation and handed me the 'palliative protocol'. I read through it for the first time in my career – I noted all the drugs I was meant to write up in her drug chart that would provide ‘comfort care’. Doses of morphine that seemed astronomical, a frequency of benzodiazepines and other sedatives that seemed unethical, amongst other seemingly absurd drug choices. I spoke with the family and they were ready to see their mother, grandmother and great-grandmother go to ‘be at peace’. I spoke with my registrar again and he seemed to want to distance himself from all of it whilst telling me I better follow the advice of the palliative team. I charted the medications, activated the palliative care protocol and then my shift ended.

Day 10 post-op, her bed was empty. I spoke with the nurse in charge of her room. She told me that our patient passed away one hour after the palliative care protocol was activated. She was surrounded by her loved ones and she felt no pain, they told me. There was a palpable sense of relief amongst the staff, and I have to admit, even I felt it. But I still had a niggling doubt and sense of guilt. Did we give up on her? Did I kill her? Why did we do any of it in the first place?