The Race To The Finish

I just downloaded a memory card from my camera onto my computer with photos from the past month. It's sureal to see photos of Shin alive and looking good. The final stages did not feel very fast as they were happening, but I sit here today and look at a photo of her looking so alive and feel stunned how quickly it all happened.

Shin has already given quite specific details of her condition, but I thought I would start with a quick recap of what medicallly was going wrong. By the end, so many different things were breaking down at once and it seemed like a race to which problem would get Shin first.

The first problem arose during the Christmas holidays. As she has written, both her gall bladder and liver where giving her problems. Her gall bladder had a bacterial infection and would normaly have been removed via simple surgery, but she was not strong enough for the operation. Her liver was 20% swollen and filled with numerous tumors that made up about half the mass of her liver. The tumors were growing fast. With her liver so weak she thought she would not be able to survive more chemo so we stopped chemo treatments on the 10th of January. She only lived for 17 more days.

The next problem that became critical was her lungs. She started to really struggle with her breathing and she was on the oxygen machine for most of the day. The doctors said the fluid around her lungs was reducing her breathing capacity. The main option was to drain the fluid in the lining of the lungs, which led to the 16 Jan post where she described her worst day so far, when the draining triggered a panic breathing episode. The draining did not have the immediate effect we had hoped. But we continued to drain about 500ml per day which seemed to reduce her coughing but didn't do much to help her breathing. But the draining process itself was lowering her blood pressure and making her feel dizzy. In fact the doctors were not able to get a diastolic reading for Shin. It became clear we would not have the option of removing too much fluid and thus she would face increasing pressure on her lungs. At this stage it seemed like a race between her lungs and her liver as to which would get her first.

A few days after the drain was put in, Shin stopped eating. It was painful to eat. It was a big effort, it made her miserable and she had no desire to eat. In fact, she had not had an appetite for weeks but had been eating because she knew she needed to to take her medication. She was aware her time was limited and didn't feel the need to prolong things by doing something that made her uncomfortable. She also wanted to do things her way and take control of her situation.

About the same time, her breathing troubles started to increase. The doctors found that her heart was racing to make up for the lack of oxygen and for the low blood pressure. So the condition of her heart and her overall nutrition entered the race to be the final straw for Shin.

Given all this, Shin's body was strong. It had always been strong. She had rarely been sick. She had amazingly few side effects to all her cancer treatments throughout the three years and had been resilient not just on an emotional level but on a physical level too.

The good news was that Shin did not have to suffer, except for a few episodes where she suffered breathing panic attacks that made her feel like she was suffocating. But essentially we were able to control her discomfort in that last week with three drugs. 1) morphine - for pain relief and to help make breathing easier, 2) Midazolam - which helped with anxiety and sleeping and 3) Haloperidal - which helped with the hallucinations Shin was experiencing as a result of both the disease and the cocktail of drugs she was on. Her hallucinations were often very simple and sometimes funny. She often thought someone was lying on her lap, or that a kid was in her room.

We increased the morphine dose quite quickly to keep her comfortable. In the last several days she was on 125mg per day. I looked up what a lethal dose was considered to be on the internet and it said 125mg per day. Shin's body was getting used to the higher doses but she was also half the size of a normal person. So the final element that joined the race to get to Shin was her morphine levels and the rate at which it was increasing. In order to keep her comfortable the morphine could slow down and eventually stop her breathing.

So in the end it was a race between liver, lungs, heart, nutrition, and morphine. And although it seemed to happen in slow motion, it was only 11 days from the draining of her lungs to her death.

This post was meant to be a medical recap of what Shin was facing. I have thoughts on the pain relief strategies that we used, what it was like to be able to care for her at home, and what happened in the final days. I'l follow up in the next few days.