Letter

During a recent farewell party, L mentioned a letter we received in 2003. Frankly speaking, the prediction in that letter was not entirely accurate, and the author turned out to be one of the most successful transplant recipients. However, it is part of our history and should be of general interest.

"Dear friends,

"When I was on-call today and having yet another dreadful canteen dinner (which would have been unbearable except for the pleasant company of LK and CM), I came up with an interesting analogy of our current predicament as contract MO.

"The moment you become a contract MO would be equivalent to having been diagnosed with liver cirrhosis which in our locality has a life expectancy of 7 years. This can be broadly divided into 3 years (Child’s A) + 3 years (Child’s B) + 1 year (Child’s C). For example, I would be a late Child’s B cirrhosis. Of course, if you develop complications such as failing your MRCP exam or getting complained for negligence your life span may be dramatically shortened, but I believe that most of us can reasonably expect to reach year 7. Knowing that you only have 7 years to live is often a source of great stress to many of us and our important lifetime decisions such as marriage and buying an apartment are affected by this.

"From personal experience, I find that with the advancement of my liver cirrhosis, I become more lethargic with reduced energy levels. I find it increasingly hard to maintain my activity of daily living such as being on-call. Although I do not have flapping tremor, my memory of my medical knowledge is not what it used to be. I have noticed many of my colleagues have progression distension of their abdomens, their waistline increasing in proportion with their liver cirrhosis.

"Like all patients, we visit our doctors in hope of finding a cure. Often we are recommended to produce case reports, be punctual for our clinics and attend academic meetings regularly which I believe to be equivalent to taking “Essentiale” capsules. Many cirrhotic patients take them but I often wonder about their efficacy. However, one should never underestimate the placebo effect especially when it is coupled with unrealistic expectations regarding our own prognosis. As our disease advances, we often harbour anger at our doctors for somehow cheating us or depriving us of therapy. However this is merely the natural progression of having liver cirrhosis and they are not to blame. They are withholding life-prolonging therapy rather than actively cutting short your life. Doctor often will withhold active resuscitation because it only prolongs the suffering of the patient. Better to die with dignity.

"Then we come to the complicated topic of liver transplantation. There is a central list that the patients are not aware of. Often political considerations affect which patient actually gets a liver. However, there are currently so few cadaveric livers available that I expect most of us will expire before one becomes available. Usually it is only a matter of being at the right place at the right time. Liver transplantation consumes many resources and doctors will often choose very carefully. Only the “fittest” patients will be considered for transplantation. There is a MELD score which is used to determine the priority of liver transplantation. In case you don’t know, MELD is short for Model of End-Stage Lackluster Doctors and is derived from a complicated mathematical formula which requires 3 variables. The variables needed for calculation of your MELD score are first, the number of papers you have published, two, the “Prof S recognition factor” and finally the inverse of your salary. For example, if you have published no papers, Prof S thinks you are a house officer and you have a high salary, you might as well start planning your funeral.

"Dear friends, keep the faith and don’t lose hope! As a Christian, I believe that death is not the end, but the beginning. I believe God has prepared a path for me that will lead me to the fullness of my life. I cannot see past my own death but I know God can and he will take care of me because of his everlasting love for each and every one of us. He has inscribed our names on the palms of his hands. As I move past this life to a newer better one, I shall look back and know how short and transitory this current life was and how narrow was my perspective. Fellow cirrhotic patients, this is merely my perspective but I hope you may find it useful."