by Henry Marsh
‘Yes. That started today,’ he said with a grimace, ‘and it smelt horrible.’ I noted silently that this was almost certainly faeculent vomiting, a sure sign of intestinal obstruction. I asked him to undress and he lay down on the trolley in the curtained cubicle.
His abdomen was criss-crossed with pale surgical scars and distended.
‘I had an op for colon cancer three years ago,’ he said. ‘There were some problems afterwards and I was in hospital for many weeks and needed several more ops.’
‘But then he was fine until two days ago,’ his wife added, trying to find some grounds for hope. When I palpated – as doctors call examining by touch – his abdomen, I found that it was as tight as a drum. When I percussed it – pressing my left middle finger onto his stomach and then briskly tapping on it with my right middle finger – there was a deeply hollow sound. When I listened to his abdomen with a stethoscope I could hear the ‘tinkling, tympanitic’ bowel sounds characteristic of intestinal obstruction. He must have waited a long time at home, hoping and praying that the problem would go away.
Something was blocking his gut and the consequences of this are no different from the consequences of a blocked sewer. It is very painful, as the muscular intestines struggle to overcome the blockage.
‘We’ll need to admit you,’ I said, using the reassuring plural that reduces doctors’ feelings of personal responsibility and vulnerability. ‘We’ll get some abdominal X-rays and probably pass a nasogastric tube and put up a drip.’
‘Is it serious?’ his wife asked.
‘Well, hopefully it’s just post-op scarring and it will sort itself out,’ I replied.
So he was admitted to the surgical ward. The X-rays confirmed intestinal obstruction, showing loops of bowel full of trapped gas. The regime of ‘drip and suck’ was instituted whereby he was kept nil by mouth and given intravenous fluid, and any fluid in his stomach was aspirated up a nasogastric tube. The idea is to ‘rest’ the bowel, and sometimes episodes of intestinal obstruction like this can indeed cure themselves without surgery. But this failed to happen and his condition deteriorated. Two days after I had admitted him, my consultant took him to the operating theatre. I was the assistant.
When we opened his abdomen, cutting through the scarred and distended skin and muscle, we found that his intestines were matted together by scar tissue. Parts of the bowel had turned black, meaning that they were dying from strangulation. Untreated, this leads to death within a few days.
‘Oh dear. Not good,’ my boss said with a sigh. He slowly freed up some of the scarred gut with a pair of scissors so that he could get his hand into the man’s abdominal cavity and explore its contents by feeling his way round the liver and kidneys and down into the pelvis.
‘Have a feel, Henry,’ he said to me. ‘Here – up by the liver.’
I put my gloved left hand – I was standing on the patient’s left side, my boss on the right – into the gaping, warm hole and felt for the liver. Its normally smooth and firm surface had a large and craggy mass in it.
‘A big met,’ I said, a met being a metastasis, a secondary cancer which has broken off and spread from the original tumour. The presence of a met usually signifies the beginning of the end.
‘Indeed, and there are mets in the mesentery as well. There’s not much to do but I suppose we had better resect the gangrenous bits as he might live for a few months yet.’
So we spent the next two hours cutting out the three short, blackened lengths of intestine and then joined – ‘anastomosed’ – the healthy cut ends together again with stitches.
In brain surgery, if an operation has gone badly you usually know immediately after the operation: the patient wakes up disabled or does not wake up at all. In general surgery, the complications usually occur a few days later, when infections set in or suture lines fail and things fall apart. With this poor man an especially unpleasant complication developed: the anastomoses of his bowel broke down and he developed multiple faecal fistulae through his abdominal wall. In other words, several holes appeared in the operative incision – and in some of the old scars as well – and through these faeces steadily oozed out. The smell was truly awful and there were so many fistulae that it was impossible for the nurses to keep them clean. He had been put in a side room and you had to take a deep breath before going in.
I saw him each day on my regular morning ward round. There was nothing we could do to help him. It was simply a question of waiting for him to die. And he was, of course, wide awake and fully aware of what was happening, slowly dying, surrounded by the terrible smell of his own faeces. He must have seen the involuntary expressions on our faces as we entered his room, steeling ourselves to brave the awful stench.
We started a morphine drip with a pump ‘to keep him comfortable’, and over a period of many days he slowly died.
I had been a doctor for three years by then but felt utterly unequal to the task of discussing his death with him. I remember him looking sadly into my eyes as I stood above him while the nurses were carrying out the hopeless task of trying to keep his abdomen clean. I don’t doubt that we exchanged a few words – probably I asked some banal questions about whether he was in much pain or not – but I know the one thing we did not discuss was his approaching death.
I will never know what he might have said if I had taken the time to sit down beside him and talk to him properly. Was I frightened that he might ask me to ‘ease the passing’, as it is called in medico-legal language? To increase the morphine and perhaps give him other drugs to end his life? I think it is what I would want if I have the misfortune to end up dying in the way that he died. Or would he have been in a state of denial and still somehow hoping that he might yet live? Or perhaps he would merely have wanted the comfort of talking about his past and memories, or even just about the weather. I remember how my eyes would drift away from him to the window as we talked, to where I could see the autumnal trees at the edge of the hospital car park. I had to make a conscious decision to force them back to look at him.
It is difficult to talk of death to a dying patient, it takes time, and it is difficult if the room stinks of shit. And I know that I let this man down and was a coward.
A few months after qualifying as a doctor, I was working as a medical houseman in a hospital in south London that in the nineteenth century had been a workhouse for the poor. It had not entirely managed to lose the atmosphere of its earlier incarnation. There were long, dark corridors and much of it was very dilapidated, as were so many English hospitals at that time.
It was my duty, as the most junior doctor, to go to the Casualty department and clerk in and admit the patients. If they needed to be admitted to the Intensive Unit, which was immediately above the Casualty department on the next floor, you had to push the patients in their beds a quarter of a mile down the main hospital corridor to the only lift and push them all the way back again along the corridor above to the ITU. If the patient was very ill you tried to run, pushing the bed as fast as you could with a porter and a nurse, but it still took a very long time.
One evening I admitted a man in his fifties with bleeding oesophageal varices. This is a condition when the veins that line the oesophagus – the tube that connects the mouth to the stomach – become enlarged as a result of cirrhosis of the liver. As far as I can remember, his cirrhosis resulted from previous infective hepatitis rather than alcoholism, the commonest cause. The enlarged veins are fragile and can bleed, often torrentially, and the patients come into hospital vomiting large volumes of blood. He was already ‘in shock’ from loss of blood when I went down to see him. To be in shock is a medical term which means that the blood pressure is falling and the patient will die if the bleeding continues and the blood is not replaced. The patient’s pulse will be ‘thin and thready’, his face pale and his periphery – his hands and feet – cold. He will have an anxious, drawn expression and his breathing will be shallow and fast.
I quickly ‘stuck in a large drip�
� – putting a wide-bored intravenous cannula into a vein in one of his arms – and telephoned my registrar, in some excitement, to say that we had a medical emergency. We transferred him the long distance to the ITU and started to give him blood transfusions. But just as quickly as we poured the blood in, he vomited it all up again. This was almost forty years ago and the only treatment available then, other than blood transfusion, was a device called a Sengstaken tube. This was a very large red rubber tube lined with balloons which you pushed down the patient’s throat and then inflated, trying to squeeze the bleeding veins shut. We used to keep them in the ITU fridge, to make the rubber harder – pushing them down the patient’s throat and into the oesophagus was very difficult because they were so large, and the patients would cough and gag, simultaneously throwing up blood. We wore aprons and boots. But despite all our efforts he continued to vomit his life away. I remember him silently looking into my eyes as I spent the night with my registrar and the ITU nurses trying to keep him alive. Every few minutes he would feebly try to roll to one side to vomit fresh blood into the grey cardboard vomit bowl beside him.
Despite giving him fresh frozen plasma and clotting factors, we were losing the battle – his blood was becoming visibly thinner and no longer clotting in the vomit bowls. It was quite obvious that he was going to die. My registrar drew up a syringe full of morphine to ‘ease the passing’. I cannot remember which one of us administered it. By now it was dawn, and the harsh fluorescent light of the ITU at night was starting to be replaced by the kinder light of the day. Once I had certified him dead shortly afterwards, exhausted, I walked back to my scruffy on-call room, which always smelt of boiled cabbage from the hospital kitchen downstairs. It was summer, and a very beautiful, sunlit morning. That I remember very clearly.
I had been a consultant for only a year. I was responsible for a man with a malignant secondary brain tumour. It was a rare tumour that at first had developed as a solid mass, which I was able to remove. But it was malignant and a few months later recurred. It was now no longer a solid mass and instead individual tumour cells were growing in the spinal fluid, as though the tumour was dissolved in the fluid, making it thick and sticky, causing acute hydrocephalus and terrible headaches. So I operated again, inserting a drainage tube called a shunt to relieve the build-up of pressure in his head. In retrospect this was a mistake, and in later years I would very rarely operate on patients with carcinomatous meningitis, as the condition is called. It is kinder to let the patient die.
The operation was not a great success. His headaches were perhaps better, but he was profoundly confused and agitated. I had informed his family that he was going to die. There was no question of further treatment and I told the family that death was inevitable, which they accepted. But he stubbornly refused to die – his life prolonged, but pointlessly, by the operation. His family became increasingly distressed by the protracted death agony, although the agony was really more theirs than his. One morning the ward sister rang my secretary Gail and asked me to come up to the ward. It was in the old hospital in Wimbledon and my office was in the basement.
‘The family are kicking up a terrible fuss,’ I was told. ‘They are demanding to see you.’ So, feeling a little sick with anxiety, and deeply regretting the shunt operation, I walked quickly up the stairs.
It was one of the old Nightingale wards – a large, long room with tall windows and thirty beds arranged in two long rows on either side. The man was in the first bed on the left, and the curtains were drawn. I cautiously put my head between the curtains. The patient’s wife was sitting beside the bed, sobbing silently, his middle-aged son standing beside her, his face red with anger. He did not give me a chance to say anything.
‘You wouldn’t treat your dog like this!’ he said. ‘You’d put him out of his misery, wouldn’t you!’
For a moment I was quite lost for words.
‘I don’t think he’s suffering much,’ was all I managed to say, looking at the patient, who was staring silently at the ceiling, mute, awake but seemingly unaware of what was going on around him. I explained that we were giving him heroin (diamorphine is the pharmacological name) through a pump, pointing to the syringe driver bolted to the drip-stand at the bed’s head.
‘How much longer will this go on for?’ asked his wife.
‘I don’t really know,’ I replied. ‘Not more than a few days…’
‘You told us that a few days ago,’ his son said.
‘All we can do is wait,’ I replied.
*
The word ‘euthanasia’ is used to describe the various ways in which doctors can deliberately bring about the death of patients. It ranges from the criminal mass-murder that went on in mental hospitals in Nazi Germany, to giving painkilling morphine to people in their final agony, to the ‘doctor-assisted suicide’ that is available in several countries for people faced with certain death from diseases such as terminal cancer or motor neurone disease, or, in a smaller number of countries such as Belgium, for people facing a life of intractable suffering from conditions such as paralysis or incurable depression. In Britain, and in most other countries, doctor-assisted suicide is illegal, although opinion polls in Britain have shown on many occasions a great majority in support of a change in the law. Doctors and members of parliament seem to have more of a problem with it than the public. Doctors rarely admit, even to each other, that they have ever helped patients die – but there can be no question that in the past it happened, and part of me hopes that it still does. You can never know, however, because no doctor wants to talk himself or herself into prison.
A doctor’s duty is to relieve suffering as well as to prolong life, although I suspect this truth is often forgotten in modern medicine. Doctors are frequently accused of playing God but, in my experience, the opposite is more often the case. Many doctors shy away from decisions that might reduce suffering but which will hasten a patient’s death. It is clear that some people can look death in the face and decide, quite rationally, that their life is no longer worth living. There was, for instance, a young Englishman who had been left quadriplegic by a neck injury while playing rugger, who went to Switzerland to die in the Dignitas clinic. There was an elderly woman who had spent her life looking after psychogeriatric patients and, as she entered old age herself, decided to end her life in the same way rather than run the risk of dementing. I consider these people to have been heroic, and can only hope that I might emulate them should I one day have to face a similar problem. There is no evidence that the moral fabric of these societies that permit euthanasia is being damaged by the availability of this form of euthanasia, or that elderly parents are being bullied into suicide by greedy children. But even if that occasionally happens, might it not be a price worth paying to allow a far greater number of other people a choice in how they die?
One senior politician told me that he was opposed to euthanasia because it would lead to ‘targets’ – presumably he fears that quotas of elderly people will be encouraged to kill themselves by doctors and nurses. This is an unnecessary anxiety: there are plenty of safeguards in the countries where euthanasia is permitted to prevent this happening. Besides, it is a question of people freely making a choice, if they have mental capacity, not of licensing doctors to kill patients who lack capacity. It will not solve the problem of the ever-increasing number of people with dementia in the modern world. They no longer have mental capacity. Besides, doctors do not want to kill patients – indeed most of us recoil from it and all too often go to the other extreme, not allowing our patients to die with dignity.
Clearly the suicidal young – as I once came close to being – need to be helped, as they have all of their lives ahead of them, and suicide is often impulsive, but in old age we no longer have much of a future to which to look forward. It is perfectly rational, on the balance of probabilities, as the lawyers call it, to decide to finish your life quickly and painlessly rather than run the risk of a slow and miserable decline. But neither the sun nor
death can be looked at steadily, and I do not know what I will feel as I enter old age, if I start to become dependent. What will I decide if I begin to lose my eyesight, or the use of my hands?
Scientific medicine has achieved wonderful things, but has also presented us with a dilemma which our ancestors never had to face. Most of us in the modern world live into old age, when cancer and dementia become increasingly common. These are now usually diagnosed when we are still relatively well and of sound mind – we can predict what will happen to us, although not the exact timing. The problem is that we are condemned by our evolutionary history to fear death. In the remote past our ancestors – perhaps even the simplest life forms with some kind of brain – did not survive into frail old age, and extra years of healthy life were precious if the species was to survive.
Life, by its very nature, is reluctant to end. It is as though we are hardwired for hope, to always feel that we have a future. The most convincing explanation for the rise of brains in evolution is that brains permit movement. To move, we must predict what lies ahead of us. Our brains are devices – for want of a better word – for predicting the future. They make a model of the world and of our body, and this enables us to navigate the world outside. Perception is expectation. When we see, or feel, or taste or hear, our brains, it is thought, only use the information from our eyes, mouth, skin and ears for comparison with the model it has already made of the world outside when we were young. If, when walking down a staircase, there is one more or one less step than we expect, we are momentarily thrown off balance. The famous sea squirt, beloved of popular neuroscience lectures, in its larval stage is motile and has a primitive nervous system (called a notochord) so it can navigate the sea – at least, its own very small corner of it. In its adult stage it fastens limpet-like to a rock and feeds passively, simply depending on the influx of seawater through its tubes. It then reabsorbs its nervous system – it is no longer needed since the creature no longer needs to move. My wife Kate put this into verse.