Mr. Leng was my patient and a family friend. He emigrated from China to Malaya at the age of 16. He married at the age of 24 and completed his family of six children at the age of forty. He started his business as a foundry proprietor in a shophouse at the age of 25. In the early years he learned the skill in tailor making small machines and repairing mechanical parts of engines and machines. Later on he ventured into manufacturing quarry machineries. He made his fortune as he succeeded in this niche when he captured the major Northern Malaya market share by supplying quarry machineries to the industries.  

He smoked since the age of seventeen. He said smoking relieved his stress and stimulate his thinking especially in trouble-shooting machine failures. He drank occasionally only during Chinese celebration dinners and festivals. At the age of forty five, he had an industrial accident where he lost his left forefoot. Despite that he was still able to drive an automatic car.  

At the age of 64 he developed a change in bowel habit, manifesting as constipation with occasional abdominal pain and nausea. Despite seeking treatment from various GPs in town, the symptoms of bowel obstruction albeit mild to moderate continued to worsen. One morning the patient noticed malaenic stools. I did a PR examination and was able to feel a rectal mass. I referred the patient to a Private Hospital where colorectal masses were confirmed by both barium enema and colonoscopy. The surgeon did a curative intent by-pass surgery with colostomy. HPE report showed adenocarcinoma of the colon.  

The article “Comparison between endoscopic laser and different surgical treatments for palliation of advanced rectal cancer (Tacke et al, 1993) studied four different modalities. The authors defined curative surgery as abdomino-perineal resection or Dixon resection in cases where there are no indication for palliative surgery like stenosis, bleeding, pain, sphincter damage, distant metastasis, bad patient control and local tumour extension.  

However, many Malaysian surgeons usually do a by-pass with colostomy as a preliminary first stage and considered it curative intent, but may also be palliative. The surgeon did not consider using expandable metal stents to palliate colonic obstruction and laser to clear luminal obstruction as these are new technology. 

The bad news was told to the patient, his wife and eldest son. The patient agreed to be given a course of chemotherapy with 5 FU (Fluorouracil). The concomitant administration of folinic acid (leucovorin) improves the efficacy of 5-FU presumably by enhancing the binding of 5-FU to its target enzyme, thymidylate synthase. However, leucovorin was not offered to the patient because the effect on survival is marginal.  Radiation therapy is not effective in the primary treatment of colon cancer. Radiation therapy, either pre- or post-operatively reduces the likelihood of pelvic occurrences but does not appear to prolong survival. As such, radiotherapy was not offered to the patient. On discharge the patient was asymptomatic. The patient ate, slept well and even worked a few hours each day despite the colostomy bag.  

On follow up three months later, the chest radiograph showed a solitary radio-opague lesion about 3 by 3cm at right upper lobe suggestive of lung metastasis. CT scan of thorax did not show other lung lesion. CT scans of abdomen, brain and bone scans were essentially normal. In view of his physical state, surgical resection was considered viable. Pulmonary resection for solitary metastatic lesion has been well documented and shown significant improvement (Sauter, Bolton Willis, 1990). Local wide excision of nodule with right thoracotomy and right upper lobectomy were carried out. The postoperative period was uneventful. HPE report of the resected lung and nodule confirmed metastatic carcinoma of the colon. The patient was subsequently given six courses of chemotherapy (5FU). He tolerated the chemotherapy well and was asymptomatic on subsequent follow up. Regular ultrasounds and chest x-rays were normal.  

Two years later the patient developed frequent epigastric pain. Up to 30% with colorectal malignancy would develop an intestinal obstruction requiring intervention. Surveillance investigations including bone scans, CT scans of brain, thorax and abdomen showed multiple masses in the liver and peritoneum. Discussion about palliative care was held with the whole family. However the patient refused contact and help from the palliative care team, as to accept such help was to deny the possibility of cure. An exploratory laparotomy was done on patient’s request which revealed extensive liver and peritoneal metastasis. The bad news that the clinical picture was inoperable was broken to the patient, his wife and eldest son. Despite the desperate situation he was in, and the impossibility of cure, the patient was keen to explore any possible treatment. The patient said in an angry tone that he was also a doctor, ‘a doctor of machines and engines’! He said that there must be a way to fix it. “My children were all successful. Over the years, I managed to trouble-shoot many difficult cases of machine and engine failures. Obviously, the doctors could do the same. I felt the doctors did not try hard enough. I would seek better doctors to fix my problem.” The patient rejected palliative care and requested the doctor and his family to take him to a Private Hospital in Singapore for further intervention. 

Successful resection of hepatic metastasis is limited to 3.5% of patients when overall survival can be lengthened especially after considering important factors like patient fitness, resectability, and operative mortality and morbidity (Blumgart 1995, Burke 1996, Kavolius 1996). For cases where resection is not appropriate, measures directed towards reducing tumour bulk can be offered to selective patients. These include intrahepatic and systemic chemotherapy, cryoablation of individual lesions, intra-tumoral injection of alcohol and selective internal radiotherapy using radioactive microspheres injected into the hepatic circulation. (A group of Singaporean doctors led by Dr.Anthony Goh, a consultant in nuclear medicine offer BrachySil, a radioactive chip to be injected into liver tumours. The method tested on five patients who had up to five tumours each showed that the tumours shrank by up to 60% in three months). 

The patient was warded for several months in Singapore. He was never offered any of the above palliative treatment for the liver metastasis. Despite another course of chemotherapy, the abdomen distended at an alarming rate. He developed gross ascites. The abdominal pain was partially controlled with opiates and pethidine injection.

At this stage, the patient was very ill but conscious and rational. He was able to take food orally. He was never weighed down by the illness. He continued to ‘fight’ the illness just like the way he fought ‘machine problems’ in his career. 

Then one day he developed headache and left hemiparesis. The neurosurgeon was consulted. The patient asked the neurosurgeon to go ahead with the operation should he turn unconscious. CT scan and MRI were done even though there was no indication at this stage. The patient lost consciousness two days later. The neurosurgeon did a shunt. I suppose it is reasonable to raise ethical issues to question the procedure even though some patients with brain metastasis present with hydrocephalus because of the blockage of the CSF pathways .The patient died two days later in the hospital.  

The body was transferred to his hometown in Penang. At the funeral, I met the family. The eldest son told me that the father refused to accept palliative care till death. He said the family spent more than a small fortune, and the doctors unethically did these procedures for the sake of money. 

DISCUSSION 

This is the case of an angry patient due to unrealistic expectation. Counselling failed primarily because palliative care is new to the doctors and his multidisciplinary team in Malaysia and Singapore.

This case also illustrates that in Malaysia and Singapore, palliative care is still at its infancy. The attitude of the doctors takes time to change. A large proportion of society is not aware of the merits and availability of palliative care. Even those who are aware may not be ready to accept the principles and philosophy of palliative care. Furthermore the society needs an appropriate framework to implement palliative care. 

The only published report in Malaysia on this developing discipline showed that doctors ‘do not refer’ or ‘refuse to refer’ (Khoo,SB, 2002). The practice of oncology has traditionally focused on the eradication of cancer. In recent years the quality of life and palliative care have become more popular. Mainstream doctors both of the public and private sectors have to accept that the rules of the principles guiding ethical issues have changed.  

The history of palliative care in Malaysia is about ten years. A decade of hospice has eased the suffering of some. However, if palliative care is to be for all who need it then the task is enormous indeed. (Devaraj, T.P.,2002). One good approach to implement this enormous task was excellently advanced in the article “Palliative Medicine and the Medical Oncologist” (Nathan &Raphael, 1996). The authors concluded that the fusion of palliative medicine and medical oncology, in practice and in education, can provide a better standard of patient care, reduce the risk of oncologist burnout, and increase the likelihood of patient, family and physician satisfaction. The realisation of this fusion will require the participation of individual clinicians, program directors, and the policy makers for cancer centres, professional organizations, and the health care regulatory authorities. 

REFERENCE 

1. Tacke, W., Paech, S., Kruis, W., Stuetzer, H., Mueller, J. M., Ziegenhagen,  D.J.,& Zehnter, E. (1993). Comparison between endoscopic laser and different surgical treatments for palliation of advanced rectal cancer. Diseases of the Colon and Rectum. 36(4), 377-382.
2. Sauter, E.R., Bolton, J.S., Willis, G.W. Improved survival after pulmonary resection of metastatic colorectal carcinoma. J Surg. Oncol. 1990, 43:135-8.
3. Khoo, S.B. PALLIATIVE CARE: EXPERIENCE WITH 156 CASES IN A GENERAL HOSPITAL. MJM. Volume 57. Number 4. December 2002.
4. Devaraj., T.P. PALLIATIVE CARE- A BEGINNING. MJM Volume 57. Number 4. December 2002.
5. Cherny, N.I., & Catane, R. (1996). Palliative medicine and the medical oncologist: Defining the purview of care. Hematology/Oncology Clinics of North America. 10(1), 1-20.