You might think that everyone with a recent leukemia diagnosis appears ill, but that isn't true. Some go to their primary care doctor with vague complaints of feeling tired or of having a cold, and a few hours after having their blood drawn are stunned to receive a phone call that they must get to the hospital immediately. Some get "stuck" in the Kübler-Ross stage of denial, refusing to believe they have leukemia even after they've received chemotherapy for it, or in the bargaining stage, negotiating for just one more bone marrow biopsy to confirm the diagnosis.
Others look like my new patient.
"His hemoglobin is 2.7," my leukemia fellow told me. A normal hemoglobin for a man should be closer to 15. "When we drew his blood, it came out almost clear."
"How many bags of blood are you going to give him?" I asked.
She hesitated. "He's refusing any blood product transfusions. He's a Jehovah's Witness."
The Jehovah's Witnesses are a religious group that believe, among other things, that only a minority of people reach heaven. They also believe that it is wrong to receive the tissue of another human being, and that doing so violates God's law, even if it is potentially lifesaving.
This presented quite an ethical quandary. To treat our patient's cancer adequately, we would need to give him chemotherapy at doses high enough to obliterate his entire bone marrow, at least for a while. During this time, he would not be able to manufacture his own red blood cells or platelets, so we would have to support him with transfusions — sometimes as frequently as daily. Supportive measures like blood product transfusions and antibiotics have led to a marked drop in mortality from the actual leukemia treatment over the past half century, to less than 5 percent. Without such supportive measures, death is almost guaranteed. Without chemotherapy, though, death is certain, at the hands of the leukemia itself.
My fellow and I walked into our patient's room to talk with him. He was lying in bed and surrounded by his relatives, who were sitting in chairs or on his bed. He smiled weakly at us, pale but handsome. We introduced ourselves to everyone and then started talking about how to treat his leukemia.
"So, you understand that the therapy we recommend has the potential to cure you, but it is unlikely you'll be able to survive the chemotherapy without receiving blood transfusions?" I summarized.
"I understand," he said.
"But if we don't treat your leukemia, you will die from it." I looked him in the eyes, at the crow's-feet that told me he had laughed a lot of times in his life, and down to his hands, holding those of his niece, sitting by his side. Tears were streaming down her cheeks.
"I know."
"I heard that you're a Jehovah's Witness. I come from a different background — I'm Jewish."
"Well, nobody's perfect!" his brother piped up. Everyone laughed, easing the tension in the room.
"I have different beliefs from you, so I can't say I totally understand where you're coming from, but I respect your faith, and we'll follow your lead on what you want to do," I told the patient. "You're the boss."
"No, he's the boss," he said, pointing toward the ceiling, and beyond. Others in the room nodded in agreement.
He declined transfusions, but he did want to receive chemotherapy, so we compromised on a lower-dose treatment, and minimized our lab draws to one per week, to preserve what blood he had. After two weeks his hemoglobin dropped to 2.1; after three weeks, it fell to 1.8. One month into his hospitalization, he became too dizzy to stand, and his heart, starved for the oxygen his missing red blood cells would have carried, just stopped beating. He went into cardiac arrest and died.
The staff on the leukemia floor took his death hard, all plagued by the same question: Had we done enough for him?
We enter our chosen profession to kill that malignant golem, leukemia. But our patient approached his leukemia focusing more on eternity than his time on earth. While many felt his belief had tied our hands so that we couldn't treat his leukemia optimally, ultimately our responsibility must be to our patient's goals more than to our own: in this case, his relationship to God, and his desire to reach heaven. I hope he made it.
http://well.blogs.nytimes.com/2013/04/25/god-and-doctor/?src=recg
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Saturday, April 27, 2013
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