Patient Care

How do you tell your first patient they'll die?

Medical school is filled with unspoken expectations. If I'm not worried I'll prove myself incompetent, I'm worried people will realize I don't always know what I'm talking about. I subconsciously expect that I'll pass tests and be able to answer an attending's questions about the mechanism of action of thiazide diuretics. If you had asked me before I started this year, I would have said that 90% of our job as physicians was to make people better and the other 10% was to help people to be comfortable as they passed away. This seemed a reasonable ratio to me, mostly healing and some comforting because of course, everyone has to die. I never realized how much I expected to heal my first patient.

My first on call experience was uneventful at best. I didn't admit a single patient and spent the majority of the night bored, all dressed up in royal blue scrubs sitting in the medical student lounge hoping to be paged. I slept fitfully in the tiny call room until my alarm woke me the next morning, a little disappointed no one had needed my "healing touch" throughout the night. So I was more than a little eager to get my hands dirty with this patient care stuff my second night in the hospital. It was around dinnertime. My senior resident instructed me to see a patient in the emergency room with suspected pancreatitis. I immediately rifled through the pages of my pocket-sized books to quickly read up on the topic in the elevator and organized the jumbled history and physical forms on my clipboard as I walked through the hallways. Ed* complained of abdominal pain. An hour-and-a-half later, my senior yanked me out of the room to run to the cafeteria before it closed. But while Ed and I interacted, something magical happened. We introduced ourselves, I tried to make bad jokes at opportune moments, and he and I formed a physician-patient relationship. That night I told my fiancé, a fourth-year medical student, that if we looked hard enough in my 77-year-old patient, I was afraid we'd find something bad.

My premonition was hauntingly accurate. His symptoms didn't fit the typical pattern of pancreatitis, and when we performed some diagnostic tests, they detected some liver lesions that were consistent with cancerous metastasis. I kept right on treating Ed, visiting him every morning, inquiring about his night's sleep and pressing dutifully on his abdomen so I could detail my findings in daily progress notes. I talked with his wife, watched baseball with him on call, and heard stories of their grandson, a basketball player traveling Europe this summer. Ed wanted me to accompany him to have his liver masses biopsies, so I asked the nurses to page me when they performed the procedure. Ed and I talked while they took samples of his liver to examine under the microscope. It was eleven days later we had to explain what all our testing meant. Ed had cancer and lots of it.

The cancer was so bad that it had started in his esophagus, next to his stomach. This explained Ed's recent loss of appetite and weight loss. He had the eight liver masses we'd first seen with ultrasound and confirmed with CT scan. It spread to his anterior mediastinum, lungs, and the lymph nodes around his celiac trunk, a major artery in the abdomen. The oncologist wrote "no hope of cure" in Ed's chart and wanted to discuss comfort care with his family.

I had been trying to prepare myself for a couple of days, knowing that the most likely result would be an unpleasant diagnosis. We walked in as a team: attending, senior resident, interns, and medical students. Ed paid close attention as our attending physician broke the terrible news. He seemed calm. Like everyday, he wanted to talk. He wanted to avoid the horrible truth of our presence, and we obliged him. Finally he looked directly at me and told me how lucky he had been to have me as his doctor. It was too much for me to handle, and I cried. Then without breaking eye contact, he asked if people could survive this kind of cancer like he had survived prostate cancer. I had to tell him. "I'm sorry Ed," was all I could choke out. "Remember how we talked about cancer spreading?" I asked. No answer. I pointed to the places in his body the PET scan had shown as metastases and choking back tears said, "It just is too many places. They can't do anything about it now." While I was pointing to the cancerous growths, I couldn't help but feel that this was my last effort to heal Ed. If all our medical technology had failed, I reasoned, just maybe physical touch could produce a miracle no chemotherapy would furnish. As I touched Ed's pink skin I couldn't escape the truth of the cancer ravaging his body. I cried some more, and Ed told me it was okay and that I didn't need to be upset, something I thought was my job. We all talked to Ed as much as he wanted, and when I left that evening, part of me felt like I never wanted to return.

Ed and I talk about once a week now. I ate pizza with Ed and his wife last time I stopped by. He tells me his pain is bad sometimes and that he wishes we could still talk everyday. He gave me a watch that he says he won't need anymore. I promise to pray for him and his family and to call again soon. I'm not sure who needs our conversations more, him or me.

Andrew Jacques ('05)

*Permission sought and granted to use patient names. Surnames have been withheld to protect patient privacy.