Mr. F points a slender index finger to the heavens and states calmly: “It’s OK doctor. Jesus will protect me.” I had just said I was sorry there was nothing more we could offer, and he was going to die. He understood … right? It had been a difficult few months for my unfortunate patient. He smiles at me softly, nasogastric tube cascading over his right cheek and then closes his eyes. I struggle to maintain my composure as I place my ice-cold hand on his shoulder and tell him I’ll return to talk to his wife in the afternoon. I proceed to the hospital stairwell and then pace for half an hour. Frantically and then slowly, going up and down six flights, holding back tears, and avoiding making eye contact with hospital staff who periodically pass me. What the hell? What’s wrong with me? I have 19 patients to still see.
I wonder why I’m having a rather strange response for an average day of tragedy in the hospital. I chuckle to myself as I contemplate getting in my car and never returning. Can you imagine?! What would I do instead? It’s a strange thought because I actually love being a physician. Is it because Mr. F reminds me of my first patient from fourteen years ago? I felt like I had been impaled as I sat silently, naive medical student, listening to her confess her utter disbelief and distress that a few weeks later she would cease to exist. Is it because he reminds me of my colleague and friend, an oncologist, who lost her own cancer war? “Dilaudid doesn’t help my heart pain,” she had uttered to me as my own heart sank, and she relayed that she was thankful for the time to say goodbye, but exhausted of doing so. Or is it because he’s only 40ish, and I’m approaching that age? I don’t know. But as I climb and descend the stairs I think about my wife and my daughter, and I try to breathe and be grateful. I try to remind myself that I’m not in a war zone, I’m not a trauma surgeon, I’m not a hospice nurse, I’m not homeless, my existence is not threatened, and I’m healthy as far as I know. So why is my hand still shaking?
I first met F three months prior. He was gaunt and yellow, and I had palpated a distended abdomen. The CT scan quickly revealed what I had feared: cancer. This was awful; a young man with decades of potential ahead of him and a likely terminal condition. The exact diagnosis remained murky even after fluid analysis, biopsies and more imaging: a carcinoma of unknown primary. He started chemotherapy and responded for a while until disappointing follow up scans. This chemotherapy was changed and temporary optimism ensued. Finally, he returned with nausea, intractable vomiting and severe abdominal pain. When the surgeon performed a laparotomy the next day he found a rigid intestine riddled with thousands of microscopic masses, thus making bypassing any occluded section impossible.
I return in the afternoon for a family meeting with F and his wife. The consultants have already made their rounds and given their dire opinions. His mood is obviously different now as he stares off into the distance without hope. I speak to his wife about hospice and try to console her. When I turn to him and ask whether there is anything I can do, he stares back blankly. What more is there? Two days later he dies at home.
Physicians are trained to diagnose, treat and heal patients and their families. We are not trained to admit plainly and simply that sometimes there is nothing for us to offer. Particularly in young patients, sometimes we do things because we see the tragedy of wasted potential and feel sincerely that we cannot give up. Extra chemotherapy is given, organs are removed, parts amputated and feeding tubes inserted. Sometimes, patients are even discharged to facilities to remain on ventilators forever (or until they meet a different grizzly end). Sadly despite technological advances, illnesses abound, and human beings still have a finite lifespan. Physicians and other health care workers are not truly trained to deal with this reality or our inevitable response to it.
Varun Verma is an internal medicine physician who blogs at his self-titled site, Varun Verma, M.D., and can be reached on Twitter @VarunVermaMD.
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