Today I met a 23 year old today who is dying of metastatic cancer. I’ve met terminal patients before and had the opportunity to work with a doctor delivering palliative care in one of the city’s hospices, but today was different. Today it was hard to dissociate myself from the patient, it was hard to separate myself from her situation. She was young with a family and under other circumstances could have been a friend and this was different than what I was expecting.
I arrived early today for my patient assignment. Today the goal was simple – I would have an hour to complete a history and physical for an unknown patient. After I had done this I would have to present my findings to the attending doctor who would then discuss the case in further detail. After the case presentation we would then head back to the patient where the doctor, myself and another student would go over the findings once again and review aspects of the exam that I had missed. I was nervous but excited – this is the closest I have come to actually practicing medicine after 2 years of study!
Things went smoothly this afternoon. I was primped and pressed, wearing a tie and a little white coat. My stethoscope and id badge in clear view, a small satchel containing some clinical exam books and other paraphernalia I thought I might need or use (an otoscope, tendon hammer, measuring tape, marker, etc). I arrived 5 minutes early, presented myself to the secretary. The secretary passed over a little sticky note that had the patient’s name as well as a chart number written upon it, promptly paged the attending to tell him I was there and ushered me up to the 4th floor. On the 4th floor I made a bee line to the nurses station where I introduced myself (always, always be nice to the nurses) and asked to see the patient’s chart.
…….hmmm, ok – age (23), id, latest vitals by the nurses (thank-you…I’ll make a note of this in case the attending asks), chief complaint – the big C. Cancer. Worse yet. Metastatic cancer. The medications tell me that this patient is on a second line of chemo – this is confusing because this is a young adult and not one that I would expect to have cancer advanced to stage where it is essentially incurable.
“Excuse me”, I ask the closest nurse, “Is this patient on palliative treatment?” Thinking that perhaps I have made a mistake and that the cycle of chemo is not really meant to be palliative.
The nurse looks through the chart for a moment, leaves and comes back with different file. “Yes – it looks like this patient is receiving palliative care.” I finish my notes and hurry to the patient’s room as I am already behind on my allotted hour.
Like I say I don’t know what I was expecting. I had read 23 years but I think I was still looking for someone older. I am standing in the doorway looking into a room with a number of different people – mother, husband, small child, and friends. Amongst these people there is one that is sick and dying. For a moment it is the worst game of “Where’s Waldo” that I have ever played. I mean it could be anyone here – or it could be the slight, thin woman on the chair in one corner of this too small room.
I start into my dialog – this is the part I’m good at – the introductions, the making of people feel at ease, lightening the mood at little. I can be personable, and in this scenario I am in some ways auditioning to not only gain the trust of the patient but also all the family and friends present. One wrong move and it won’t be the patient that I will have to worry about, it will be her mom – chasing me down the hallway battering me with her handbag. But today I prevail, and manage to weasel my way close enough to the patient to begin the interview.
Even though I have made a good first impression, I am still not out of the woods. The patient is guarded, her mother present and her husband watches from close by. It’s hard enough to gain the trust of one person in a short period of time to a point where they will talk about about intimate details, but it is exponentially harder to gain the trust of multiple people in the room and yet (somehow) I am able to do it. This means that after 30 minutes or so I can finally begin to talk to the patient in earnest and hope to get a smidgen of the physical done as is expected of me by the attending doctor.
The details of the interview are of course private. The only thing I can say is that it occurred to me that my impression of this person’s disease and her impression of her disease were completely different. In some ways the sheer idea of a terminal disease, especially someone younger than me, is terrifying. For the patient, the disease was a challenge and a cure was the hope. I knew from her chart that she will die soon, but I couldn’t say if she had been told by her doctor as to how bad the cancer in her body really was…and honestly who really could sit her down and take away the little hope she has with such a brutal discussion. I have a respect for those who do this, who work with the dying. I have seen how they have frank discussions with patients still not ready to accept and I could see one such talk happening in this persons future and it made me sad.
For the moment, I take comfort in that the person I met today is surrounded by friends and has a beautiful family. For her, she will have love and support until the end. And for me, I have her to thank for time that she gave to help with my learning despite it being the most limited thing she has left.