Other Features: Teaching and Learning Moments
Keirns, Carla C. MD, PhD
Dr. Keirns is clinical lecturer in internal medicine, University of Michigan, Ann Arbor, Michigan.
Near the end of my internship, Mr. P. was admitted for a pulmonary embolism. He was a dignified man, with dark silvering hair, wire-rimmed glasses, and a pile of books and journals at his bedside. When I returned later that afternoon, his wife and son were there. The son looked vaguely familiar, and he confirmed that we had met in medical school, where he was still finishing. Less than a month ago, the patient’s low-back pain and leg numbness had led to x-rays, then a CT. A biopsy confirmed metastatic lung cancer. He felt quite well. In his hospital room, he smiled, laughed, and joked with family and friends. For me, though, Mr. P. had the haunted look of a man who did not yet know how little time he had left.
My patient’s pulmonary embolism was found by CT, and he was eager to know what else the scan showed. With the patient’s consent, his son reviewed the scan with me. The cancer was widely metastatic, taking up nearly a third of one lung and producing lesions in multiple bones. I watched my colleague’s eyes as he scanned his father’s report, and saw him pause. At that moment I wondered if I would have known what to say if I had spent less time memorizing biochemical pathways and more time studying divination. How does a fortune-teller deliver bad news?
After rotating on the medical oncology service, assisting at lung resections as a medical student, and losing my stepfather to metastatic lung cancer, my vision of Mr. P.’s future was darkened by the outcomes I had seen. But I held back that guilty knowledge. How much detail should one give about events not yet certain, no matter how likely?
We went into his father’s room, and I told his parents what we knew. Yes, we could see the cancer on the scan. Of course there were options for treatment. No one asked me how long he had. That was fine with me, because I didn’t want to answer. I struggled with supporting their hope and tempering it with reality.
Two weeks later, he was back.
Now Mr. P. had bleeding from damage to his intestines from radiation. He was still dignified, but pale and washed out. His wife and son looked to me as if they had aged a year in the two weeks he was home. We had to strike a careful balance between managing his pulmonary embolism and his gastrointestinal bleeding. I sat up all night at his bedside with his nurse, pouring in blood products to match his losses and reversing his anticoagulation because the bleeding wouldn’t stop.
In the morning his son came to find me. “He has a facial,” he said anxiously. “Can you come check, but don’t scare my parents?” I went into the room with a smile and shook the patient’s hand. While Mr. P.’s grip was strong, his returned smile drooped on one side. His son was right. There was little anyone could do to stop the relentless progression of his cancer.
A week later, my patient was rushed to intensive care in the middle of the night. When his wife woke their son, at first he was afraid. Then his growing knowledge and experience kicked in, and he rushed to the hospital in part to make sure his father was not put through futile efforts at resuscitation. The least we could do, he said, was let him go gracefully. His son’s gift to his father, his growing medical knowledge and insight, was also a burden as he balanced what to say, when to say it, and when to just be there.
Carla C. Keirns, MD, PhD