I finally got a chance to read Atul Gawande's recent piece in the New Yorker, titled "Letting go," on hospice care and the medical profession's systematic failure in managing the dying process. It's an amazing article, and Gawande is an amazing writer. One graf jumped out at me:
One Saturday morning last winter, I met with a woman I had operated on the night before. She had been undergoing a procedure for the removal of an ovarian cyst when the gynecologist who was operating on her discovered that she had metastatic colon cancer. I was summoned, as a general surgeon, to see what could be done. I removed a section of her colon that had a large cancerous mass, but the cancer had already spread widely. I had not been able to get it all. Now I introduced myself. She said a resident had told her that a tumor was found and part of her colon had been excised.
Yes, I said. I’d been able to take out “the main area of involvement.” I explained how much bowel was removed, what the recovery would be like—everything except how much cancer there was. But then I remembered how timid I’d been with Sara Monopoli, and all those studies about how much doctors beat around the bush. So when she asked me to tell her more about the cancer, I explained that it had spread not only to her ovaries but also to her lymph nodes. I said that it had not been possible to remove all the disease. But I found myself almost immediately minimizing what I’d said. “We’ll bring in an oncologist,” I hastened to add.
“Chemotherapy can be very effective in these situations.”
She absorbed the news in silence, looking down at the blankets drawn over her mutinous body. Then she looked up at me. “Am I going to die?”
I flinched. “No, no,” I said. “Of course not.”
A few days later, I tried again. “We don’t have a cure,” I explained. “But treatment can hold the disease down for a long time.” The goal, I said, was to “prolong your life” as much as possible.
I’ve seen her regularly in the months since, as she embarked on chemotherapy. She has done well. So far, the cancer is in check. Once, I asked her and her husband about our initial conversations. They don’t remember them very fondly.
“That one phrase that you used—‘prolong your life’—it just . . .” She didn’t want to sound critical.
“It was kind of blunt,” her husband said.
“It sounded harsh,” she echoed. She felt as if I’d dropped her off a cliff.
This was striking in part because I have had to have this conversation many times over the last few months. This is not exactly a normal part of the practice of Emergency Medicine. In fact, I had this conversation just yesterday, and it went badly.
This was not a subtle diagnosis -- a sixtyish year old man with back pain and a huge, lumpy liver on exam. I got the CT and it showed innumerable nodular mets in the liver (probably colon primary but not certain). I sat own to tell him and broke the news as I usually do, along the lines of "Well, I got the scan results, and it gives us an explanation for the symptoms you have been having, but unfortunately, it's not very good news." (Pause here for the patient and family to brace themselves.) "We saw a number of spots on your liver. Based on the way they looked on the scan and based on what we have seen in the past with similar images I can tell you that this is almost certainly cancer."
This is generally where we go off-script. Once you drop the C-bomb, the reactions are all over the map. From tears to hysterics to calm questions, you never know where the conversation is going to go.
In this case, the wife reacted fairly typically with a gasp and tears, but the patient just kind of stared at me and said "OK, then." I thought, either he didn't hear me or he's in denial. I'd better emphasize the point a bit. So I added that while we didn't know the primary site of the cancer, it probably came from somewhere else and once cancer spreads to the liver, it is much more serious. Still no reaction.
"Do you understand?" I asked, and finally he responded.
"Yup," he said, "It's about what I figured. I've had a pretty good run. Thanks, though. I guess I'll be on my way." I tried to engage him in the next step -- seeing his doctor, an oncologist, chemo, etc, but he was uninterested. "No, I'm just gonna let this thing run its course."
Ah hell, I thought, I overdid it. Now he's already being fatalistic. Eventually I got him to agree to meet with his doctor and the oncologist (his wife was my ally in getting him to concede even that much). Lord alone knows whether he'll follow through with anything more.
He was probably shocked and maybe depressed, too, but I felt a little bad about dropping him off of the proverbial cliff.