Death is an inevitable event that eventually comes to each living being.
This week, I had to walk the journey with the family of a patient who was critically ill.
Siew Ching (not her real name), 66, has stage four breast cancer.
While she had responded well initially to chemotherapy, the disease took a turn for the worse when the cancer spread to the brain.
She is single but comes from a family with many siblings.
During the two years that I have looked after her, she had been accompanied by her youngest sister or eldest brother at each clinic visit. They would be involved in the decision-making process and, more significantly, they were there to support and encourage her to fight on.
They obviously care for her and love her dearly.
During a recent hospitalisation, I often saw either or both of them in her hospital room when I visited her at 7am during my ward round. It meant that they had either slept overnight in the ward to keep her company or had rushed over from home very early in the morning to catch me on my morning visit.
They would update me on their observations and wanted to be kept informed about the treatment plans.
All appeared well initially. However, Siew Ching's medical condition gradually worsened. Over the course of days, her speech became increasingly slurred and eventually incomprehensible. She then lapsed into a coma.
Besides the two main caregivers whom I was familiar with, other family members started giving input on what they thought should or should not be done.
This was by no means a straightforward decision.
The brain is a part of the body that often serves as a sanctuary site because many chemotherapy drugs cannot penetrate the membrane that covers the surface of the brain and spinal cord.
This membrane, called the meninges, serves as a natural barrier that protects the brain.
However, it also serves as a "filter" and can prevent many medicines from reaching the brain.
That is why the effectiveness of chemotherapy on cancer that has spread to the brain is generally lower than for other parts of the body.
The preferred treatment option for patients with cancer that has spread to the brain is radiation therapy. In most cases with multiple tumours spreading to the brain, the entire brain is treated with 10 sessions of "whole brain irradiation".
This is often successful in shrinking the disease in the brain, and reducing the symptoms caused by the space-occupying tumours.
Sadly, Siew Ching's radiation treatment had to be abandoned as her overall physical condition deteriorated and she had to be admitted to hospital for supportive care.
The family became divided into different camps. Some wanted her to stay in hospital so that she could receive maximal supportive care.
Others wanted her to be discharged so she could go back home, while some wanted her admitted into a hospice for terminal care.
When I sensed that there was conflict and disagreement within the family, I suggested that it was best that we all sit down together to understand the situation and come to a consensus on how to proceed.
These family conferences are never easy. It is important to ensure that everyone understands the patient's current medical status, treatment option and likely prognosis.
All who are present must be given an opportunity to express their personal views.
In Siew Ching's case, the eldest brother wanted very much to keep her in hospital and to do everything possible.
However, another brother and a niece (who represented another of Siew Ching's brothers) were clear that they did not want any further active treatment.
With much reluctance, the eldest brother gave in to the other two.
The meeting concluded with the consensus that there would be no further active treatment and that Siew Ching would be discharged as soon as possible to a hospice for terminal care.
As she was then recovering from a bout of shingles, the hospice was not prepared to accept her until the infection was totally cured. This is a precaution against the spread of infection to other patients.
I continue to see her every morning. But, sadly, she is now all alone in the room. Gone are the family members who used to be there each morning.
I asked the nurses and they, too, had noticed that the family visits had become infrequent and brief.
Her days are now quiet. Death will come soon to take her away.
While her family members were united in wanting the best for her, their strongly held convictions and bitter disagreements about how to care for her have changed family dynamics and ties.
Hopefully with her passing, there will be reconciliation.
- Dr Ang Peng Tiam, medical director of Parkway Cancer Centre, has been treating cancer patients for 27 years.