“I’m so sorry, but it looks like the cancer has spread.”
As I heard these words come out of my mouth, I knew that in a split second, a new reality was created in the mind of the patient that I was talking to. I looked at his face and saw that he was trying to remain strong, but in his demeanor, it was apparent that dreams were crushed and that hope of recovery was taken away. He had the appearance of a man who fought a long battle with everything that he had, and when he found out that he lost, fatigue and heartbreak were etched on his face. However, I did not see the marks of a man who walked on this earth for many years; I saw a young man who was supposed to be entering the prime of his life. In my mind, I saw myself being the best man at his wedding, running around on the soccer pitch trying to set him up for a goal, or holding his young kids as he told me how it was being married for a few years. “These words aren’t supposed to be for him,” I thought. “Why him?” But as I looked at him and saw how weak he was, and saw the tears of a mother and wife who also went into battle and saw the end result, I knew that these words were meant for him, even though I did not want them to be.
During this recent conversation, I had an immediate flashback to when I first met him as a resident and I remembered being intrigued by his story when I read his chart for the first time. He was only a few years older than me, but he already had metastatic colon cancer without a prior family history. He had been making progress with chemotherapy, but he started having progressive fatigue. He was brought to the hospital and was noted to have worsening anemia and thrombocytopenia, raising concern for bone marrow failure due to his cancer. As I stepped into the room to introduce myself, I first saw the patient and immediately was taken aback by how young he was. For a brief moment, I wondered how someone so young could be so sick and so weak; he had significant swelling in his legs, he had a pale appearance, and every breath he took was a struggle. He was surrounded by family members who were trying to remain strong, but I could tell they had the same thoughts I had as they looked at him with loving concern.
I introduced myself to him and we started talking; during the span of a few minutes, we started connecting. He started talking about sports and I chimed in about how I thought some teams were going to do that season, and immediately, the burden of concern was lifted for a brief second. Laughter filled the room, and I knew that having a patient close to my age allowed me to connect with him the same way I would with an old friend. I saw the immediate therapeutic impact that it made; for a split second, he was able to enjoy talking about things other than his illness. By the time I left the room, he appeared more comfortable, and rather than being aware of a power dynamic between doctor and physician that could occur with a greater difference of age, he saw me as a peer that could relate to the normal thoughts, dreams and fears he had that come with young age and were only magnified in the setting of illness.
During his hospitalization, he slowly regained strength, but not without a few setbacks. At times, blood transfusions were a daily occurrence, and the constant beeping of the monitor in his room set his family on edge. Daily updates consisted of answering numerous questions from his family about prognosis, and it was clear they were looking for signs of hope for recovery. As days passed, I got to know him more and he started telling me about personal aspects about his life, particularly his faith and his family. It was apparent that these two things were what kept him from losing composure, even when I overheard tense conversations between his wife and his mother about his care and expectations of recovery, and saw the pain in his eyes when he heard from his wife about those interactions. Not once did I hear him complain, which was remarkable. ”If anyone had any right to complain,” I thought, “it was him,” but he chose not to.
Even though I was his doctor, I started to develop a closer relationship to him; with us being close in age, it was easy for us to relate about various things. Perhaps it was the uncertainty about cancer that created the space for real intimacy, but by the time his hospitalization was over, I had gained a new friend and he felt the same way about me. I was glad to see him walk out of the hospital a little stronger than when he came in, and I wished him well.
A few days later, I saw his name appear on my census, and immediately I started worrying. I knew he was sick, but I did not think he would come back so soon. I saw him in the emergency department and he looked worse than before. Each breath was more of a struggle, and the same look of concern that I saw in his family members became my own, because this time, it was not just my patient I was looking at; it was my friend in that bed struggling to hold on. As I pulled up his chest imaging, I feared the worst and hoped that it was not what I was expecting it to be. I started scrolling through the images and when I finished, I wondered if there was any part of the lung that was not infiltrated by cancer.
With each scroll of the images, I felt an increasing sense of sadness for him and his family, and each scroll brought me closer to the time that I would have to start one the hardest conversations I have ever had with a patient. It was a rapid progression of disease from what I saw a week ago, and I started to realize that his fight to beat the cancer was ultimately lost. As I headed toward his room, I had to figure out the words to say, because I knew that by the end of the conversation, things would never be the same for him or his family. It just didn’t make sense or seem fair that I would need to talk about worsening illness and death to a young man whose life should reflect the opposite of these things.
By the time I was ready to discharge him from the hospital, I had spent more time with him, trying to prepare him to leave the hospital comfortably with his family. Ultimate arrangements were made for him to go home with hospice. It felt weird doing this for someone who was only a few years older than me, but at the same time, I felt honored to be a part of his life in his final days and that he shared intimate aspects of his life that only a few were privileged to have access to. On the surface, it seemed cruel for this to happen to someone so young, but I also was happy that while I took care of him as his doctor, I also shared his journey as a friend. As I finished my time on service, I had a feeling that this would probably be the last time I would see him alive. I thanked him for teaching me about handling illness and death with grace, and for allowing me to befriend him; I wished him well as he prepared for his last days.
He ended up passing away a few days after discharge, and his death initially affected me deeply. There was a genuine sense of sadness; perhaps it was the fact that he was so young, or that we developed a close relationship, but it felt as if I lost a close friend. I sent my condolences to his family which they appreciated, but while they were dealing with their own grief, they unexpectedly took time to help my grief by letting me know how much he appreciated my care for him as his doctor and my brief but important friendship with him. Hearing this helped to ease the pain of knowing about a beautiful life which was unexpectedly cut so short. I never knew a young patient would have such an impact on me, but I am a better doctor for it, and I hope that I can give my other patients the same gift of intimacy he allowed me to cultivate.
Chiduzie Madubata is an internal medicine physician.