Mrs. Liu, who was only 58 years old, had metastatic ovarian cancer. Despite radical surgery and chemotherapy, her disease persisted. Worse yet, her PET scan from a few months ago revealed that she had carcinomatosis — numerous deposits of cancer showered throughout her abdomen. This particular night, she starting having more nausea and couldn’t eat or drink anything without vomiting. So, she came to the ED. I was called into consult, and after talking with her, I laid hands on her abdomen: it was firm, unmistakably full of tumor. The subsequent CT scan confirmed that she had a malignant bowel obstruction. And now that the cancer had blocked her intestines, she was no longer able to eat.
Mrs. Liu and her family members were blindsided by the news. They were scared and anxious. Of course their first question would be: How do we treat her next? Can we fix her with surgery?
And so there I was.
To the ED physician and me, it was obvious: “Fixing her with surgery” was not an option. Surgery can no longer help when there is diffuse spread of cancer. There were no good treatment options. Chemotherapy and radiation, which had obviously failed in the past, would likely have a modest effect at best — and she was too weak to receive much more. In short, curing her disease was no longer possible.
Surgery residents are regularly thrust into this ugly moment of cancer patients’ lives: when the eleventh hour has passed, and there is nothing else that can be done. We — instead of their regular physicians — are then forced to reconcile the cruel reality of the disease with the patient: that they are simply too far gone. Without that awful truth, patients do not understand why surgical intervention is not realistic.
This situation highlights a significant flaw in our care of late-stage cancer patients: We need to stop sugarcoating our prognoses. Patients with advanced disease should meet a surgeon or palliative care physician early in their care to discuss how they are going to die. We should be helping patients understand what to expect when the disease progresses. It may help minimize excessive interventions in the hospital as well as aid patients in focusing on their personal lives — not just the next scan or the next treatment.
Our guidance can help them make the most of the precious time they have left.
When doctors get cancer, it’s striking how little treatment we choose to receive. An older surgeon once told me that if he were ever diagnosed with pancreatic cancer, “I would be OK with one surgery if they could get it all. I absolutely would NOT do chemotherapy … I would quit my job, travel while I’m still healthy, and spend whatever time is left at home with my family.” Although an extreme example (the outlook with pancreatic cancer is more dismal than other common cancers), it illustrates how physicians prioritize the quality — not the quantity — of the life they have left.
Without the proper preparation, it is difficult for patients’ families to desire anything beyond wanting more time with their loved ones. So it came as no surprise that Mrs. Liu’s family still wanted us to “do everything possible.”
But Mrs. Liu interrupted: “Is it OK … to not do anything? I’m sorry, but I’m very tired.”
I responded to both requests with a question of my own. “What is it you’re trying to live for at this point?”
If she wanted to make it to the next graduation, wedding, or birthday, we could do everything to help her live a little longer. We could temporarily force the blockage open with a stent, give nutrition through an IV, or attempt to place a tube in the stomach to release the pressure and relieve some of her discomfort.
However, if she wanted to spend the rest of her days at home with family as comfortably as possible, we could that as well.
She chose to have a gastric tube placed to alleviate the nausea and to return home with her family as soon as possible. A few days later, I saw her son in the cafeteria; he thanked me, then said she was at peace with what was decided. I voiced that while I was glad I was able to offer them a little insight, I felt sorry I could not do more.
As he walked away, I couldn’t help but wish that they could have been guided through these difficult decisions when there was much more time to spare.
James Wu is a surgery resident who blogs at Back to the Suture.
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