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Medical Humanities

Facing Glioblastoma: The Predator

Saumya M Shah

January 18, 2019

“Saumya, why don’t you present Mr. C, a 35-year-old male with chemotherapy-resistant glioblastoma status-post surgical debridement and resection.” I was stunned. This was the first day of third year of medical school and clinical rotations, and the first time I was given a patient to follow. It was also the first time I was going to see a patient with a glioblastoma—the same predator my uncle succumbed to one year before—ironically, on that exact date. I profusely scribbled every word in my pocketbook, nodded to my senior resident, and embarked on a journey to find Mr. C’s room in the maze of hallways.

He lay paralyzed on the hospital bed, with one eye rolling in all directions without purpose, and the other looking straight ahead at me. The ventilator next to him hummed as regularly as a metronome beat. The spikes and troughs of the heartbeat kept on ticking as if they were loyal servants to the body, not quite ready to lead a rebellion against the organ. His wife informed me that his only method of communication was an occasional blink of his one eye, sometimes suggesting intact comprehension, and other times only intact life.

Mr. C’s glioblastoma journey had begun eleven months prior with transient seizures, similar to the presentation of my uncle’s arduous journey. In the following months, the “Cs” would make countless trips to the emergency department, transfer between world-class institutions for that one extra clinical trial, and undergo repetitive surgeries to debride infections that were a result of prior surgeries. I met Mr. C and his wife on their fourteenth hospitalization, and unlike previous visits, Mr. C presented with severe dysphagia necessitating percutaneous endoscopic gastrostomy (PEG) tube placement, a risky procedure due to his unstable condition. A goals-of-care conference involving palliative care, neurology, ethics, and Mrs. C was organized. The team emphasized the challenging crossroads they were at and the option of comfort care: undergoing another intervention was necessary for Mr. C’s life to continue, yet actually performing it would likely end his life. Despite fully understanding the situation, Mrs. C was adamant to continue with the PEG tube placement. She felt that regardless of how pain-free the process of death in comfort care would be, how could she voluntarily sign up her conscious husband, her best friend, and her partner in life to slowly starve to death? She was fully aware that every additional medical intervention was incrementally decreasing his quality of life; however, she was not ready to say goodbye.

I walked out of the care conference wanting to scream but unable to. On one side, my thoughts aligned with those of the team. Since day one of medical school, we were taught to do no harm. Would having Mr. C undergo yet another procedure be considered harming him? Or should a physician’s goal be to save a life? Was it ethically appropriate to funnel endless medical resources towards a patient whose deteriorating prognosis was certain? On the other hand, like Mrs. C, if my spouse was hanging on to the cusp of life, I do not think I could gather the courage or moral fortitude to let him pass.

With endless years of medical training, we gain the privilege to study every intricacy of the human body, identify the prognostic signs and symptoms of life and death, and learn to intellectualize every situation that comes our way. At the same time, this state of no longer being ignorant of knowledge takes away the bliss of ignorance. We are faced with colliding forces: the intellectual voice that critically examines the situation and calculates every hazard ratio and survival probability based on the given patient facts, and the emotional voice that focuses on the relationship ties and tears that surround the patient and his family’s suffering. My aunt, a physician herself, likely had these exact conflicting thoughts upon first hearing the words “glioblastoma” and “husband” in the same sentence. Like all physicians, she learned early in medical school that this was one of the most merciless predators towards its prey. I witnessed her struggle with the difficulty of attempting to forego her identity as a medical provider to be a caregiver to her husband. Fulfilling a physician’s duty in a way that combines the inner calculative scientist and the sympathetic human into a synergistic energy becomes a challenge. Nonetheless, at the end of an emotionally demanding day, this role as a provider of health brings more contentment and peace than any other profession imaginable. I like to believe that this is because of the relationships that we form with the patient and his or her family. The emotional capacity required to be a sufferer’s care partner at his or her weakest moments in life is expansive—sometimes demanding so much that it leaves little for one’s own self. Yet, the resulting bonds, though often limited by the course of the disease, are what make this profession so fulfilling.

Like most other ethical situations, there was no right answer to the one right in front of me. In that moment, I longed for an algorithm on UpToDate to help guide decision-making. Ultimately, Mr. C underwent PEG tube placement and was subsequently discharged. Two weeks later, I coincidentally ran into him in a different hallway of the hospital with a different medical team—although, there never was another hospitalization after that one.

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