How do you tell a 24 year old that she is dying?

Physicians are no strangers to death. We are baptized into medicine with cadavers as first-year medical students. We learn to break bad news. We lose patients, some that are expected and some we never see coming. Through it all, we maintain a distance, an emotional reserve that enables us to shoulder these losses but still see the next patient with the full attention they deserve. But every now and then we lose a patient, and that loss stays with us. One thing that we don’t learn in medical school is how to grieve these losses.

For me the grief came in my dreams, three consecutive nights dreaming that she was still alive, that the phone call notifying me of her death had been a mistake. She still had time. I would see her on rounds tomorrow.

How do you tell a 24 year old that she is dying? Just seven months ago this conversation was unthinkable. Seven months ago she went to a local Emergency Room for chest pain and had a CT angiogram that diagnosed a pulmonary embolism. The CT also found a lung mass. Next came the biopsy which confirmed everyone’s worst fear: cancer. Non-small cell lung cancer. She was referred to my hospital’s cancer center where she underwent two rounds of chemotherapy before starting immunotherapy. For a time her disease was stable. Then came excruciating back pain and the MRI which showed a pathologic fracture of the lumbar spine. She underwent radiation, and her pain medications were increased.

This was a setback, but she remained hopeful. Then came the shortness of breath and hypoxia and the home oxygen. After just a few weeks, the oxygen wasn’t enough to allow her to get the bathroom without becoming winded. She returned to the hospital, and another CT showed new lung nodules. She was started on antibiotics, and everyone hoped this was just a pneumonia while fearing the real culprit was the progression of her cancer. Oncology was consulted and planned to resume chemotherapy if there was no improvement with antibiotics.

This was the point when I took over her care. During the seven days I was her doctor, she didn’t get better with antibiotics; rather, as everyone had feared, she steadily got worse. Unfortunately, during this same weeks’ time, she became increasingly thrombocytopenic, sparking concern the cancer was now in her bone marrow. This was the line in the sand. With the severe thrombocytopenia, she was no longer a candidate for chemotherapy. Her oxygen needs increased by the day. There was no treatment left to offer other than palliation. She asked me if dying would be painful if she would be conscious and gasping for air. I promised her she wouldn’t suffer. All the while, her husband sat on her hospital bed, crying, unable to look at me.

Two days before she died she was sitting up in bed putting on make-up when I made my rounds, asking how my day was going. Within 24 hours her dyspnea became so severe that she could no longer get out of bed. Another 24 hours and she was gone, just two hours after signing a DNR. I knew her for only seven days, but her death and my unexpected grief for the life she never got to live have stayed with me far longer.

Jennifer Caputo-Seidler is an internal medicine physician.

Image credit: Shutterstock.com

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