The end is nigh

Saturday, 1st October, 2016

We are counting the hours now. That is the amount of time that Dr SD has given N to live. This follows blood reports coming in that show N's WBC counts exceeding 99.28 billion cells per Litre, a creatinine level of 2.43 and potassium level of 7.6 mMol/L. She has no infection, the blood culture report was clean. The leukocyte count is purely the cytokine response due to metastasis.

Anyway, we have put N on a 5% dextrose drip with 10 units of insulin to control the potassium levels. The creatinine is not that worrisome. N does show signs of kidney failure, though, which was probably brought on due to dehydration.

There is nothing we can do for the inflammatory response, that I can think of. It has not been caused due to an infection, or we could use antibiotics. Corticosteroids is an option, but hasn't been used much in end of life treatment from what I have read. Neither did any of the doctors suggest it. I re-read parts of my old immunology textbook to find it very lacking. It limits itself to infection, not to the pathway as such, so was not of much use to me.

It is sad that the awareness about the inflammatory response in cancer is lacking amongst medical practitioners in India. Perhaps targeting that pathway could have helped N. I regret not using the ayurvedic medicines now. Many were targeting that pathway.

However, I can see much headway being made in cancer medicine, which should help millions fighting against this terrible disease in the near future. It is sad that N will not be there to make any use of it.

I can see N's temperature going down steadily. It is now 96 F.

It is a waiting game now.

Crash and (not) burn!

What an eventful few days, ranging from heart-stopping agony to pure relief, and hopefully, a degree of recovery.

N's oral intake has been consistently reducing over the last 3 days, leading to reduced urine output, lowering blood pressure and visibly increasing discomfort. Our GP has basically recommended that we let N die, as painlessly as possible, giving her water when she asks for it, and not forcing any intake. This has, unsurprisingly led to dehydration, and its consequences at 4:00 AM on 28th September were scary.

We were urgently called to N's room by my uncle who had been woken by the nurse. N was exceedingly uncomfortable, seemed in agony and was breathing volubly and oddly. Her oxygen saturation was scarily low at 81. We called up my cousin, a doctor, currently living in the US, and he suggested we rush her to the hospital. This idea was immediately dismissed as it could mean that N would lose her life in an impersonal ICU with no one at her side. Taking the risk into consideration, a further patch of fentanyl was applied to at least ease her pain, and the backrest of the bed raised.

While N's children (my mother and uncle) sat by N, perhaps seeing her off for the last time, I rushed, along with my brother to a 24 hour chemist to procure an oxygen cylinder. It was impossible to get a proper sized one as most medical equipment stores were closed, so I returned with a refillable 1000 mL cylinder that could at most be deliver 0.5 L of oxygen per hour. Happily by the time we got back, N was enormously better, with her change in position (and perhaps eased pain?) bringing her oxygen back up to 97.

When the world woke up, we ordered a full sized cylinder, and returned the tiny thing that we had bought. It is now on stand-by, should the need arise.

Come afternoon, we were visited by a pain specialist, who does house calls and works in palliative care. Dr SD felt that N need not be left to die, and that hope was not lost. He suggested (much to my mother's disgust), that a naso-gastric feeding tube be inserted to give N some much needed nutrition. She agreed after being reassured that it would not cause her pain. However, he also felt that this could be done only after she is stabilised and her mouth, now infected, be treated. He suggested we have an IV line inserted in the mean time, a task that proved rather difficult for our nurse due to the dehydration.

What followed was an adventure to a nearby charitable hospital whose staff exceeded themselves in helping us. An experienced nurse attached to the hospital came over, after her shift ended to help us with N, completely out of the goodness of her heart. Faith in humanity was restored!

N is currently in repose. She did not like getting an IV line, and we would have respected her decision if her electrolyte imbalance were not interfering with her decision making abilities. Dr SD feels that N would probably stop needing the IV line in 2-5 days. Let's hope that she can have her nutrition orally by then.