When the patient says "no".

This is a report about S.K., a woman who suffered from cancer during the last 8 years of her life, but continued to exercise her free will, and to participate actively in her medical management until she died. This was only possible through an empowering and transparent patient–doctor relationship. Doctors and patients are often faced with the dilemma of undergoing management options which are medically indicated, but do not fit the patient's lifestyle or goals. The doctors' duty is to furnish all available options, but more importantly to respect the patient's choices, including how they want to die. S.K. was a 55-year-old woman who presented in November 1999 with clinical evidence of mechanical intestinal obstruction which had insidiously progressed from partial to complete. She had a previous history of left radical nephrectomy with left adrenalectomy 1.5 years prior to hospitalization , followed by radiation therapy to the kidney area as treatment for hyper-nephroma. Besides having proximal bowel obstruction , she was found to have a large, 8 cm diameter right adrenal tumour. No evidence of any other tumour deposits was found. I explained to her and her family the situation, the advantages and risks of the operation and the possible complications. She consented to the surgical intervention. I operated on her with the preoperative diagnosis of complete proximal small bowel obstruction and right adrenal tumour. I performed exploratory coeliotomy, lysis of adhesions, side-to-side enteroenterostomy bypassing the grossly abnormal irradiated bowel, and right adrenalectomy. During the first week postoperatively, the patient continued to produce large amounts of gastrointestinal fluid through the nasogastric tube and continued to vomit. I explained the situation to her and her family. The family had a number of inquiries and worries. She overruled them, and said to me, " Do what you think is appropriate. " She was re-explored, found to have an obstruction at the anastomosis site, and stenosis of the whole segment of the bowel used for the anastomosis. Therefore, resec-tion of the entire grossly abnormal small bowel was performed with duodeno–jejunal anastomosis in the 4th portion of the duo-denum. This time, the postoperative course was smooth. S.K. was discharged in the second postoperative week with oral cortico-steroids replacement. She was followed up in the general surgery clinic until her wounds healed and she had normal gastrointestinal function. Then she was discharged, to be followed up in the endocrinology and the medical oncology clinics. During …