Reflections From the Front: Knowing When to Say When

Reflections From the Front: Knowing When to Say When

Palliative Medicine. Many physicians become so focused on their piece of technological turf that they don’t put the patient and the real clinical issues in appropriate perspective. Often the best course of action is no further technical intervention, but a change of focus to relationships, comfort and symptom management.

I wrote this anonymized poem as I was thinking about our patient. I changed the sex, and tried to be a little vague with the medical details, but wanted to capture the main point of our encounter.

A Step Back

(The Technological Imperative)

The old man hits the wards with nasopharyngeal cancer with “mets” to the brain.

Despite any conceivable intervention, his prognosis is in weeks, not months.

And, thanks to his increased brain pressure and morphine, he is feeling no pain.


When he presents with systemic infection from an infected ventricular shunt,

We say

“We can fix this.”

We can SurgicallyremovethetubeTreatwithantibioticsGotosurgerytoreplacethebraintubeGobacktotheICUwithaventilatorDorepeatedspinaltapsTreatanynewcomplicationsAndhopethenewshuntremainsinfection-free.

All of which will take three weeks, and during which time

He won’t wake up enough to say Good-Bye.

Fortunately for him, he took a nosedive, and he and we were saved from ourselves.


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