Life's tough and then you die

I had an interesting patient this week that has given me a lot to think about. The brief explanation of what brought him in will help illustrate what my thought process has been like. Here goes.
He's an 87 year old guy with some dementia and his daughter is his Power of Attorney (makes medical decisions for him now because he can't). He has been getting weaker for the last 6 months, eating 2 meals a day for the last month and 1 meal a day for the last week. He comes in for this weakness and in the course of his testing it's found that he has a golf ball-sized tumor on his lung and another one in his small bowel. This one in his stomach causes him to become totally blocked up. At this point there are really 2 decisions that could be made.
1- Get a very large surgery.
or
2-Get some palliative care and go home to die there.
From a medical standpoint, here is what I see.
Option Number One: If they choose option one you are faced with the reality that his cancer has already spread and has done so a while ago (as evidenced by the tumor in his lung). This is a very poor prognosis for anyone, meaning the surgery that is being offered is not curative, it will only help with the symptoms of an intestinal obstruction. He will likely do poorly after the surgery because of his declining health and poor nutrition and will spend a week or two in the hospital and likely at least a couple of months in a nursing home/rehab facility before going home at all. Remember this hasn't cured him and he will likely die relatively soon from this cancer. It is also important to remember that there will be significant (read: excruciating) pain with the surgery that will slow healing and slow down return of bowel function prolonging hospitalization. Because of any surgery and hospitalization there is the very real possibility that he will have a complication such as infection. Finally, not to crude, but there is the very real situation of finances. The average day in the hospital costs $1000 a day and a stay in the ICU can be $10,000 per day. Not to mention the cost of a nursing home for weeks after being discharged from the hospital.
Option Number Two: A small bowel obstruction is not a fun way to go. Your stomach still makes gastric juices, the bacteria in your belly still make gas all of which can't get past the obstruction and this is very uncomfortable. This also means that you can't eat anything and you will likely die in a matter of weeks. We can put a tube down your nose that can vent these gasses and suck out the juices, or we can put a tube through your skin to your stomach to do the same thing to make you more comfortable. We can do many things for pain control to make you comfortable at the end. Eventually you will die, but you will be at home, reasonably comfortable and surrounded by the people you love in the place that you love. Also, not to be crude, but this option is much cheaper than the previous option.

What would I want if this were me? Take me home and let me die. People spend a fortune, experience so much pain, and endure procedures that ultimately won't buy them more than a couple of weeks at best. All this and 75% of people die in hospitals or nursing homes when an overwhelming majority of Americans want to die at home. Part of this is due to a separation from death and people not seeing the natural process of it. Part of this is due to the belief that we can somehow buy a new lease on life. This last part is partially true, but often not for any meaningful length of time and at tremendous cost physically, emotionally, and monetarily.

I had hoped that this family would have taken their father home and used what little time they have left just being together. That would have been a "good death". Unfortunately he chose the surgery and is now in a great deal of pain recovering from a 6 hour surgery. At this point I just hope that he recovers well from this and the benefit is worth this cost to him.