Thursday, August 10, 2017

there's no need to say goodbye

This is not a post anyone wants to read, but I am writing it nevertheless because I foolishly reread Elizabeth Bishop's One Art with impeccably bad timing.

I signed two death certificates this week.

Ms. H was an anxious ball of nerves who initially thought she could live for several years with metastatic renal cell carcinoma. But after a surgery to remove a significant deposit in her spine, when it came time to medically treat her cancer, she had a change of heart. She was a strong-willed woman who had been diagnosed only because she could no longer carry bricks into her backyard as she had been doing for most of her life. She lived alone and though she had children, she felt strongly that she did not wish to be a burden on them. She passed peacefully at home. I knew her for less than a year.

I inherited Mrs. G from a physician who had left. She was supposed to just be monitored to make sure her cancer stayed away, supposedly in remission. The first time I met her, she had new neck pain, and the next day, she was in the hospital getting an aggressive sarcoma excised from her cervical spine. She should have lived for six months after that, but for a while radiation held the sarcoma at bay. She saw me every month, with her two daughters, one with healthcare experience who kept trying to prepare her mother for the end, the other with no healthcare experience who wanted her mother to fight until the bitter end. The two sisters would squabble, and sometimes the medical assistants would tell me they were about to brawl in the examining room. But when you grow up in a South Asian family, loud sisters don't frighten you. The sisters would always apologize afterwards and Mrs. G would always make some joke.

One of Mrs. G's daughter's had a son in college, all the way out in EBF, where I grew up. It was one of those details that patients and their families believe bind you to them. Because it does.

She beat the odds, and when I say she beat the odds, I mean that it took a year before the cancer came back. As if to give us all the middle finger, the cancer came back vengefully, in her nerves, starting by making her face droop on one side. Then her legs started to go numb. The cancer was laughing at the chemotherapy we had attempted. She asked three times if she could still come see me if she went on hospice. When I told her she could, she was satisfied. But she died two weeks later.

As if the week was determined to mock me, Mrs. P was hospitalized.

Mrs. P is in the process of dying. She has a rare cancer that spread into the lining of her abdomen, and it wasn't even entirely clear from where it stemmed. She asked me a dozen times when we first met a litany of questions: How did this happen? Where did this start? How much time do I have? Why me? She is one of those patients who can articulate exactly the experience of having cancer and living with cancer. She would tell me about episodes of rage she had about not being able to do things she used to be able to do. She would tell me about fights she had to wage with insurance companies and her intentions to make them rue the day they messed with her. For two years the cancer behaved itself, and then one day, it just stopped behaving, undoubtedly picking up some mutation that made it grow more rapidly. Her belly started filling up with fluid and she had to be hospitalized because her nausea was uncontrolled. The surgeons confirmed there was nothing they could do.

In the hospital, Mrs. P was being looked after by a fourth-year medical student, and a senior resident. I worked with the senior resident when she was an intern. It was breathtaking to see her now leading a team of patients. Still, neither the student nor the resident wanted to have a conversation with Mrs. P about her cancer. It was fine by me. To be honest, I can be a little greedy, a little bit of a control freak about my patients. The student and resident came into the room with me, and listened as I told Mrs. P about the cancer progressing, about the lack of treatment options, about how it was time to start focusing on getting her feeling as well as we could.

She looked at me, not a somber molecule on her face. She looked at me matter-of-factly really, and nodded. "You're not telling me anything I didn't already know," she told me. And it was true. Just the week before, when she was starting to feel poorly, we had talked on the phone, and as I talked to her about some medications she could take for nausea, she had confessed to me, "I think I'm in the end run here." I'm still early in my career, but I've never heard a patient say something like that and then end up living another year. Patients always know, and oftentimes before the physician does.

Mrs. P made sure to thank me, and she said a kind word about the care I'd provided her. When the medical student, the resident, and I walked out of the room, I spontaneously told them that though such conversations were difficult, this was what made my job so worthwhile. They both looked at me like they were contemplating a psychiatric consult.

I guess I sometimes don't see it from the outside anymore. You know, Valar Morghulis and all that, so to me, what's important is the journey. And there are few more meaningful journeys you can have than the final one. No one gives a care about the physician during this journey, and let me be clear in saying- nor should they. What we do as physicians is not particularly noble. But we are lucky, as anyone is lucky, when they accompany someone down a bad path, a final path. Some patients don't find peace at the end either, they fight and are bitter about their illness until their last breath, and that's something fortunate to witness too.

Even when I don't like my job, I do love my job. And weirdly I realize it more on a week like this, when I'm assigning causes of death and giving patients the bad news that their time is almost up.

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