Saturday, August 1, 2009

Bad News

M.K. was 5’4” weighing it at only 100lbs, but she was feisty. You could tell she was a knockout before the cancer came. She had big blue eyes and blond pixie haircut reminiscent of Meg Ryan in her Sleepless in Seattle days. She had come to our care after noticing blood in her urine. Didn’t think much of it – she had been battling cervical cancer for five years and figured this was just another bump in the road in her fight against cancer. Thus far, she had been through surgery, radiation, and several rounds of chemotherapy. And despite the orange-sized mass protruding out of her left backside, she anticipated being out the door almost as soon as she came in. Unfortunately, the bleeding persisted. And then, her platelets dropped. A week later, the bowel obstruction came. Her tumor had grown into her intestine and she was no longer able to pass stool through a portion of her large intestine. The nausea and vomiting became so bad, she couldn’t eat or drink. A CT scan revealed that the tumor was now 4mm away from invading her spinal cord. A week and a half after she came into the hospital, the oncology team knew she would never leave alive. But M.K. didn’t.

Being human presents a big obstacle in providing good medical care. It is simply not in our nature to be the bearer of bad news. We want to impart hope, to heal, to cure. Unfortunately, there are many times in medicine when the only thing a patient needs is the truth. The cold hard truth.

Thus far in my short career in medicine, I have seen too many times what happens when doctors are afraid to tell patients and their families the truth. At best, a patient lives the last months of her life with the false belief that she will eventually get better. And she is subjected to the pain and discomfort of tests, procedures, and medical interventions that do nothing to prolong her life and everything to prolong false hope. At worst, it means a patient dies in a cold hospital room surrounded by white coated strangers, with tubes coming in and out of every orifice and ribs cracking under the force of CPR.

I have also seen the alternative. A great oncologist at my hospital always tells his patients the same thing when they first meet. “You are well now, and we will do everything we can to keep you well. But there will come a time when I will have nothing left to offer you. And when that time comes, I will say to you, we are done.” We had that talk this week with another patient, K.A. Because she had had time to think about it before, she was able to say, “Okay, I am done fighting. I just want to be comfortable. I want to live my last months at home with my horses and dogs and die surrounded by my family.”

The same went for M.K. and her family. Before we had The Conversation, her family wanted everything done. It didn’t matter if how futile or physically painful it was, they felt this obligation to do everything to prolong the life of their daughter. And the dutiful daughter M.K. was, she felt obliged to go along with it. Each time we walked into the room, the anxiety was palpable.

Then The Conversation came. M.K. and her family learned that with the way things were going, she would never make it to treatment. She didn’t have much time left and now we were asking M.K. how she wanted to spend the remainder of her life. The room swelled with sadness and tears that afternoon. But curiously enough, it also swelled with relief. The patient and her family had finally been given permission to let go. It was if they had needed to hear that it was okay to stop fighting.

The useless medical treatment was replaced by comfort care. The IV was taken away. The daily injections were stopped. The anxiety in the room disappeared. Shortly after, M.K. started to lose consciousness. It won’t be long before she’s gone, but when she is, her life will end in the most peaceful of ways. Without pain, surrounded by friends and family in a room filled with love.


  1. I read this fantastic article in Sports Illustrated today and the first thing I thought about was your post. I think you'll see why:

  2. I had a patient who was with our attending that was not realistic with her patients about impending death. She had already undergone 3 complete chemo cycles with different drug combos, and had a permanent chest tube at admission for pain management. By the end of her stay she had undergone additional placement of tubes in various places, scopes, imaging and countless labs. Everyone was "fighting" and there was no acceptance that she had reached the end of the line. Finally after a 2 week admission for a battery of tests and procedures the attending said she was done. The patient still didn't get it because that was impossible to comprehend in just one day. She died just one week later and I still can't get her off of my mind! Not sure that I will do Gyn Oncology, but if I do, or when I'm faced with these discussions, I will definitely work to draw the line sooner.