A local surgeon called me to refer a patient with curable cancer. He had informed this 71-year-old woman that she required chemotherapy and surgery. The patient became frightened and resistant to the idea of treatment. She told the surgeon that she would refuse any therapy. She “wanted to die.” The surgeon’s response? “Then, I have just the doctor for you.”
Now perhaps it is an act of denial but I choose not to take this referral as an indictment of my medical skill. I am thickheaded enough to believe he referred the patient not because he thought death was more likely under my care, but because I might be able to persuade her to accept therapy. She agreed to see me in the office and we arranged a consultation immediately.
It is important to declare my bias. This otherwise healthy woman has a cancer with a 70% cure rate. While I accept in theory this patient’s right to chose death over treatment, in practice I had no intention to present those alternatives in a balanced fashion. The patient would have to supply the argument against therapy. I planned to present the case for life.
Entering the room I noted a slightly ill kempt older woman was sitting fully dressed on the exam table. She was accompanied by a younger woman, whom I took to be her daughter. The patient had no wedding ring. She appeared generally healthy, but tired. She had been crying. She combined poor eye contact with a weak handshake. She was not happy to see me, and resented the intrusion. After introductions, I had her move to the chair by my desk.
I asked her to explain what had brought her to the office. After several evasive answers (“the doctor sent me”) and a little prodding, it became clear I want to know about everything that had happened. She began to talk, and except for an occasional question, I listened. I kept eye contact with the patient, effectively ignoring the daughter. We walked, step by step, threw the scary tale of the last few weeks … symptoms…doctors…tests…. results. Included were several moments of humiliation and anger. Twice she cried. Then, we stopped for a moment. I handed her a tissue and touched her hand.
We did not focus solely on the new oncologic problem or medical past. I tried to learn personal details, such as work, religion, personal passions and the can-never-be-overestimated makeup of her family. She lived by herself after the death of her husband and was close to several grandchildren.
After this initial informational bonding, I stepped out of the room so that she could rap herself in a flimsy blue paper gown. During the exam, I kept up a banter of non-medical gossip. We talked about her granddaughter (Anne is graduating College next week, actually has a job), her dog (7 year old Pug), her unusual brooch (southwest turquoise) and her garden (roses and tomato’s). I explained she seemed healthy, except for the abnormalities previously noted. I stepped out to let her assume human clothes.
We sat again at my desk. What did she know about the disease and its treatment? What had she been told by other doctors? She had some understanding of basic concepts, but emphasized the complications of even successful treatment. I asked her how important it was to her that she continue to live alone? She responded she did not want to be a “burden.”
I told her the story of her illness. How and when it had started (“you have had this for years, it was very small”) and how it had grown. I explained what the tests and biopsy meant and made certain she understood the terminology. I told her that this cancer was usually curable. It would require patience, work and treatment, but she would live. With planning, she would be able to stay by herself during most of the treatment and was likely to return to full independence after completion.
Nonetheless, I pointed out that she could never be a burden on those that loved her. What they needed most would be to help. Her best chance to be independent was to kill the cancer. Again, she took a few minutes to cry.
We walked the path of treatment. This I wrote down, making certain the patient heard, and the daughter understood. Each test and treatment step. I listed the likely and possible side effects. Several times, I made certain to make her laugh (consider getting a green wig, we draw lots of blood tests because we sell it, you can not do dishes so your daughter must take you out to eat often…) The conversation moved into the practical, “how we get through this” mode.
Just before we closed, I told her I wanted to ask what would sound like a tough question. I needed to understand her wishes not just for now and this battle with cancer, but for the future. I was not making a prediction, but trying to understand her better. I needed to know what she would want if something terrible happened to her which could not be fixed. I used the example of a severe stroke. If she could not be “saved” would she want to be placed on machines, life support or have CPR? She declared that she would never want to die “on a breathing machine.” I confirmed the daughter had heard those words.
We finished by creating a written plan. Made an appointment in one week, just to talk. I gave her a hug and explained once again, that while she had work ahead, this was a battle to cure her disease. I think she now understood that not only could the cancer be treated but that the fight was worth it. She had many reasons to live.
The visit was a transition from denial and fear with a focus on loss, to careful planning and a culture of life. We never talked directly about her initial “I just want to die.” Instead, we came to a realistic understanding of her disease, her treatment and her future. We created a viable alternative to suffering. What could be done and what was likely to happen. We gave her the tools to have an element of control. We raised the hope of living not as a cancer patient but as a survivor in a community of grandchildren, flowers and chubby small dogs.