When Is Enough?

I saw Mr. L again on his second hospital admission in one month as part of the palliative care team. He returned to the hospital because things had become increasingly difficult at home. He'd continued to lose weight, his appetite was diminishing, and now, he spent much of his days sleeping. His wife reported that trips to the bathroom had become arduous. We set up a meeting with his primary oncologist.

“We may be reaching the end of the road,” the oncologist shared. And then, “but there is one more targeted therapy we could try.” With thorough discussion that success of this treatment would be measured in the potential of a few more months, Mr. and Mrs. L chose more cancer-directed therapy. As Mr. L put it, “I want a chance at more life, I just don't want to feel any sicker than I already do.”

I met with Mr. L the next day when he was alone and having more difficulty breathing, as fluid slowly filled his lungs. “If you asked me today whether I'd like to live or die, I'd say die,” Mr. L asserted. Silence. I let that sentence sink in. “Are there things we could improve about your life, so that you wouldn't feel that way?” I asked. We talked about his pain as well as increasing medication for his shortness of breath. We talked about partnering with his nurses to try to get out of bed each day. Most of all, we talked about how to accept help from people around him, as this conflicted with his nature and his understanding of himself as a provider.

“I'm worried…” I began, “When you say that if given the choice, you'd rather die, I'm worried that pursuing more treatment for your cancer and transition to rehab to try to get stronger may not match up with what's most important to you now.” Mr. L nodded, “I'm not sure rehab is for me. But my wife will tell me when she has had enough.”

Later, I spoke with Mrs. L over the phone. “How do you feel about how things have been going?” “It's been a fucking nightmare,” she replied, “each day it's something new.” She apologized for swearing, but I told her that I'd never heard a more appropriate use of the word. We explored her worries about the path ahead. “I want to support him on his journey. If he has an ounce of hope that this treatment might give him more time, then I want to believe that too.” She paused. “He'll tell me when he has had enough.” I suggested she come to the hospital so we could talk further.

With permission, I shared the conversations I had been having with each of them separately. “I've heard the same sentiment from both of you, that each of you believe the other will say when they've had enough. I'm wondering if this is something we can all talk about together?”

Mrs. L climbed on the bed, took her husband's hands, and looked into his eyes. “I will never have enough,” she said through tears. “Selfishly, I want you to live as long as you can, but not at the expense of your suffering.”

“I am not suffering,” Mr. L replied, “I haven't had enough either.”