This week’s writing challenge with the Daily Post aligns perfectly with something I had intended on writing about anyway. Except instead of just writing, they suggest I do it in email form.
Hello Surgical Team in a hospital far, far away,
How are you today? Good, I hope, despite some of the rain we have been getting lately. I guess it is better than they humidity you have been having all summer. Things here have been hectic as usual, but I kind of like it that way.
I just wanted to let you know we saw Mrs. X here last week. It is pretty crazy how she somehow was so well and out and about as if nothing was wrong just a month ago except a cough chalked up to allergies and then was in hospital in respiratory distress. I am sure you were just as shocked as I was to see the giant mass blocking air entry into her left lung. Well, I guess based on the clinical picture, it wasn’t quite as shocking.
Needless to say, based on what you were saying the weekend before, she would probably die over the weekend, so we held off bringing her down. I mean, obviously surgery can’t fix it and radiation is the best option, but you can’t have someone die on an ambulance ride to get palliative treatment. That just isn’t right. But, she stabilized and survived the weekend.
In fact, when I was paged to go see her, I still expected to see someone frail and unwell. But, instead I found Mrs X. On 15L of oxygen, but sitting up in no distress reading a novel. You didn’t mention how sassy she is. My attending was off seeing another consult, so I started taking her history and was floored at how well she was and how sick she got. I also quickly realized that although they knew surgery wasn’t an option, she and her son were oblivious to how bad thigs were. There was no cure. In fact, this lady was dying. Maybe not as quickly as we thought last week, but quicker than you and I. And she had no clue. None. All she knew is it was a lung cancer causing the trouble. And they had to drain the fluid from around her lung. Not that she had no air to her lung, that the tumor was invading a main vessel and the heart lining not that she had big mediastinal and hilar nodes and a 2cm lesion in the opposite lung. She just new she was coming for a “shot of radiation to help fix [her] breathing.”
We did the radiation plan. A single fraction and then she was to return home. After planning, she became acutely distressed and we had to give her morphine to settle her.
We sat down and talked with she and her son. They hadn’t heard the cancer spread. That having this kind of fluid on the lung is a bad sign. That the tumor is so big and so extensive we can’t treat it all and, actually, we don’t even know if the radiation will make a sigificant difference.
Amongst themselves, they had still been talking cure. Or at least a few years. Her other children live far away and she had assured them not to worry, not to come home.
We were looked at as if we had ten heads talking about symptom management. They knew we were just for the breathing, but they still hoped something else was being done. She wanted to go home soon. And here we were explaining that things weren’t good. That home may be difficult with the high oxygen need and talking about getting palliative care involved. About doing things sooner rather than later. About having her kids come home.
They appreciated the honesty. They understood what we were saying.
It felt terrible being the bearer of bad news. Not that we don’t do that every day, but because they were at your hospital for days and oblivious.
I know sometimes people don’t hear what you are saying. You can tell them bad news or good news and they just hear what they want to hear. People get overwhelmed with things. So, maybe you did tell them and they didn’t understand.
I also know we, as physicians, get overwhelmed. You forget to go back. Or you are scared to go in and say things like palliative and no cure and such. Especially when you are so busy and you don’t deal with this stuff as often. I know, It would be easier if you could have just cut it out or referred her on. I have sometimes let things go because I was scared, especially when I am unsure of details. And sometimes, people are vague or they seem to get it, but they don’t. Those people are easy to gloss over. Easy to brush off in your mind, perhaps. But, sometimes, they need even more attention. I am not perfect. I screw these talks up. I am just starting out and I screw up all kinds of things. But, I think it is better to try and to care and want to help. Talking to people about death and dying is scary. But, that isn’t fair to the patients or the family or the other staff to avoid the topic or to not address it appropriately.
I am not speaking on a stereotype here. I am not trying to type you just because it happened. People often think surgeons are cold and harsh. But anyone can be cold and harsh. I am saying this because not everyone is and no one has to be. Stereotypes are just stereotypes. People can get beyond them. In fact, I think you have gone beyond them before. You talk to people about tough stuff all the time and care very much.
I think you have done a lot for these people, even if it wasn’t cutting the tumor out. It just bothers me that, in a way, they were left on their own because it couldn’t be cut out.
I also know some of the team member’s hands were tied. You can’t say anything until someone ahead of you does. I have been there. There is a chain of events. I know how distressing it is and what a moral-ethical battle it is. Thank you for being there for these people. I hope this makes you think about your decision as much as it has made me think about mine in the past. I hope you know you are doing the best you can.
I am glad we got to help this family. I like seeing people be aware of the things to come, know what they should be doing and understanding what is happening right now. I am sad that they had to hear this kind of news from physicians they just met. I am upset that you didn’t give me a heads up about how much they didn’t know or what you chose not to cover. And, selfishly, I am mad that the lack of information you left them with caused multiple hiccups in my day and in the way I was perceived.
These things happen. We all have off days and strange encounters. I know it is not your habit to have these sorts of things happen, but I all the same, it is not the first time I have seen people in similar predicaments. Communication is so important, especially in these life threatening situations. This lady could have died and it would have shocked everyone more than it necessarily would have to. We need to make time for people and for these tough situations. Even though it is scary.
Sorry to be so harsh. It is just that I really have a heart for people in these situations. I want to help the dying live. But, I believe honesty is so important and I feel that they could have been signficantly hurt by the approach that was taken.
On a brighter side, Mrs. X had a good laugh when we had to take her picture for the ID for treatment. She was unimpressed, as she didn’t put on make up and thought we were only going to take pictures of her chest. She also said she is very grateful for all of your help, as she is much better than she was when she came in to hospital.
You are great at what you do, but just don’t forget the people you care for.
Say hi to Mrs. X for me. Take good care of her. Keep me updated.
This is what I wish I could say to the surgical team who does a lovely job at what they do, but turfed us with a very sick and oblivious patient and family a few weeks ago. The good thing is, scenarios this bad don’t happen that often. The bad thing is that they still happen.
**The details of this case were obviously changed to protect the privacy of both the patient and the team caring for them.