To care always: Physician writing contest second-place entry

"Is it bad?”

Of all the questions to be asked, that is certainly one of the worst, particularly when you’re a junior resident on Christmas Eve, and you know that, in fact, it is. Yet there he was, gently tugging at my sleeve from his hospital bed, voice held low so his wife across the room would not hear. And there I was, leaning over him, poised to move his St. Christopher medal so I could listen to his heart.

I could have evaded it, avoided the responsibility and said we should wait to hear what the consultants would say. But we had already discussed it, in advance of the family meeting that would be starting any minute. And here was Mr. Davis, my patient, asking for an honest answer, and I knew what it must have cost this silent, stoic man to ask that simple, terrifying question. “Yes,” I said quietly. “I’m sorry.”

He nodded, and fell silent. Lying there in bed, he looked well enough, so long as you didn’t ask him to stand without his wife’s and daughter’s help, and if you ignored the plastic tubing emerging from his upper abdomen. The drain had relieved his itching and the yellowed tint of his skin, but would not fix the baseball-sized mass nestled within the head of his pancreas. The family meeting was to discuss what could next be done. Unfortunately however, it seemed that there would be very little to offer.

The rest of the team arrived: the other residents and the attending, followed by the gastroenterologist and the oncologist. Earlier that morning we had scrutinized his imaging and testing, and had agreed that this was not something that he could survive. But now, as the talk moved past the test results, to the concern for advanced pancreatic cancer, to the treatment options, the real issue of prognosis seemed to have been left behind.

The consultants were good physicians, and they had the best intentions, but no mention was made of his inevitable decline and the final outcome, or of ensuring the quality of the time he had left. Instead, the conversation focused on the need for additional testing before deciding on the best treatment plan, behind which lay the unspoken yet implied promise of a cure. In the back of the room, I frowned to myself. Could I have misunderstood our earlier discussions? Could Mr. Davis actually have a fighting chance? It now sounded as if the outcome was not so certain after all. And if I, who should have known better, was left with that impression, what must Mr. Davis and his family think?

NEXT: "This is his last Christmas"

The patient and his family listened, but didn’t have many questions. As the meeting ended, I excused myself and hurried out after the exiting consultants. I caught up with one of them at the charting station as he was writing his note.

“Excuse me,” I said, “back there it sounded like you felt that he had a pretty good chance of coming through this. Do you actually think that he might be okay?”

He snorted. “No. He’s going to die.” He finished his note and walked off, adding, “He’ll be lucky if he lasts six months.”

I was still standing there as the rest of the team emerged from Mr. Davis’s room. The attending and senior resident began planning the next steps, while the junior residents silently waited for their instructions. Between arranging for biopsies and additional imaging, and when any actual treatment might begin, it looked as if Mr. Davis could expect to be in the hospital for quite some time, especially given the holiday season. They were still hammering out the details when someone interrupted them.

“We should send him home.”

I hadn’t really meant to speak, but there it was. The attending and senior resident stopped and turned towards me, surprise on their faces. There was no turning back.

“It’s Christmas Eve. And tomorrow’s not only Christmas, it’s Saturday. When do we think these tests will actually get done?” No one answered, but they didn’t need to. We all knew the chances of getting tests and studies done around holidays or long weekends.

I looked around at the team. “We can’t fix this. And this is his last Christmas. Spending it in the hospital, waiting to get testing done, won’t get them done any faster. I say we send him home, let him spend Christmas with his family, then bring him back next week to get the tests done. “

My words seemed to freeze in the air. I had just recommended a plan that I had never heard anyone propose during my short medical career, much less actually order. The attending continued staring, and I felt my career fading away into the silence.

At last, the attending spoke. “Let’s do it,” he said.

Within a few hours, he was on his way home. He returned the next week as planned, had the additional tests done, and then went home again. He died at home, about a month later, surrounded by his family.

I still think about how, ultimately, we had very nearly failed him. No one chooses medicine out of a desire to hurt others. But sometimes, our desire to prevent suffering actually may have the opposite effect if we forget that the scope of our patient’s lives consists of more than their medical ailments. Over two thousand years ago, Hippocrates is supposed to have said: “To cure, sometimes; to help, often; to care, always.” I suppose that even today, we have to accept that sometimes one out of three isn’t so bad after all.

Kenneth Moon, MD, is a family physician who lives in Silver Spring, Maryland.