He came to our large, urban teaching hospital in search of a cure for his stomach cancer. We met during the workup stage of his care while he was suffering from intractable nausea, yet we still needed test results before we would know what kind of treatment we could offer.
He came to our large, urban teaching hospital in search of a cure for his stomach cancer. We met during the workup stage of his care while he was suffering from intractable nausea, yet we still needed test results before we would know what kind of treatment we could offer. It’s sort of a horrible waiting room experience that goes on for days to weeks, or even months at a time--every patient knows this time all too well. As the oncology fellow on the service, I was assigned to see and direct patients through their workup phases, before the actual cancer diagnosis had been made or clarified with tests.
I have to tell you that this particular patient taught me some hard lessons that I didn’t realize I wasn’t ready to hear. The thing is that stomach cancer has a unique staging procedure called a laparotomy that is used to detect whether cancer cells have taken up residence or "seeded" in the abdominal cavity. It is a must-do procedure because it determines the utility of curative treatment. He was a healthy, older gentleman (octogenarian actually) without other considerable medical issues and could have undergone a long, curative surgery safely. I very much wanted him to be cured.
His laparotomy detected malignant cells. I was guiding his workup and now needed to break the news that the direction of care had changed course. He would not be able to get what he came for. I asked the patient when would be a good time to talk. I pondered many questions in my mind: What did he know about the stomach cancer so far? What would he like to know at this point? How would he like me to tell him? Was it important for family or friends to be around? I sat close on the edge of the bed, spoke slowly and deliberately, and made sure he understood. Ever the southern gentleman, he was polite to me the entire time, but would not look at me. I had gone over the necessary details, asked permission, and basically done everything by the book. We even had a pretty good rapport up to this point.
I must tell you. I felt horrible. I left the room feeling like I had just violated many social mores, and worst of all, I felt that I actually just hurt someone, which I had. I had done what I was taught and trained to do, and it felt so wrong. I was beside myself wondering how this healthy, mild mannered gentleman could be so wronged, and how is it that we can do nothing to take away his disease. In essence, I think I felt the same deceit that he was feeling, that life isn’t fair at all.
During the next few weeks many things happened. We orchestrated other doctors to get involved with his care to make sure nutrition was not a problem, and that his nausea lessened. We discussed treatment options, but the biggest event was the gathering of his nine children from all over the country. There were many opinions and even quarreling. He and I became a team explaining how everything had happened as they were wrapping their minds around it. He had clearly always been the patriarch and this was not an easy adjustment for them.
I realized however, that he was able to guide them through what was he was going through, and in essence, comforted his family in the way he had probably done many times before. It was a role that gave him much pride.
The time made a difference.
The unfortunate reality was that he grew sicker quickly and was never able to leave the hospital. During the intervening few weeks, he did much work with himself and his family to prepare for all the things they and he needed to do. Later, as I was now on a difference service, I learned that he was again offered a course of palliative chemotherapy that could potentially ameliorate his symptoms. But instead of risking increased debility (without a clear benefit to chemotherapy or guarantee that it would work), he had decided on a hospice service and to focus on enhancing the quality of time he had left. Actually, I had offered him chemotherapy originally and was excited for him to receive treatment-I felt as if I had to do something for him.
I had to know what drove his decision. When I asked, he said, “Doc, when I first met you, I thought, that’s just my luck to get this lousy doctor, but then I realized that I actually had the best doctor."
I was touched of course. There could be nothing better than to be considered the best doctor by your patient, especially one who you thought you had failed.
He was able to reconcile issues with his family. The time to do that had been a gift. Without being able to receive a cure, he realized that time was the next best thing. He shared his stories about growing up on a farm, and how important his father’s lessons had been for him. I listened. That felt right to me. I was so happy that he shared those stories.
Daniel McFarland is a clinical fellow in hematology and medical oncology at Mount Sinai Medical Center in New York City and a member of the American Psychosocial Oncology Society. He is dually trained in internal medicine and psychiatry. As part of the American Psychosocial Oncology Society, Dr. McFarland is currently collaborating with Dr. Jimmie Holland at Memorial Sloan Kettering Cancer Center in an effort to bring psychosocial issues to the attention of oncologists as they treat patients in the new era of personalized medicine. The views expressed are his own.