Jyoti Mayadev, MD
Department of Radiation Oncology
University of California Davis Health System
In life, there are times when we actually prefer to be present at the beginning. Perhaps to be on time for a new patient consult, a continuing medical education event when you need to sign in to get your credit, the beginning of a movie to not feel lost, or the dreaded start of your oral medical boards. You have to be there, and the event won’t wait for you to saunter in.
On the other hand, there are instances when you can fill in during the middle, such as that mandatory departmental holiday party, or for the non-football fans, the catch of the Super Bowl Sunday halftime show. What has been most poignant for me as a radiation oncologist has been the privilege of being present at the end for a patient.
In the beginning of my radiation oncology training in Seattle, I particularly remember a patient with metastatic cancer of unknown primary, James. I had seen James over a course of months, being treated on various services. I had an instant connection with James and knew the family well. In the beginning they were all there, and the room was always packed. The doctors felt awkward taking the seat, and the medical students were pushed behind the dressing curtain. In the middle, the crowd thinned. The eldest daughter had her own small children to attend to, the third son’s work excuse ran out despite our repeating signatures and efforts, and the sister had her own ailing family member.
And then, there was the end. The medical team all knew it was coming, and although I was in my infancy of training, I knew it too. It was a Thursday evening and I went to check in on him with his wife. He had a very long day of tests and soon his decision would need to be made. Should he continue with us to try to prolong the middle, or allow himself to be at the end?
Suddenly, the end attacked us too quickly. I had seen him throughout the year, but at that moment, it was like we just met yesterday. “Yes, Mr. X, we know you have cancer, but we don’t know where it came from. We know this is serious, but treatable,” the usual script. We passed a couple of glances and we all knew this was the right decision, to allow the final portion in the rule of thirds to manifest in the softly lit room.
What was most striking and memorable to me that night was my inclusion as an integral portion of the end. In the midst of dozens of family members who supported him during the beginning and middle, I was the one standing next to his wife at the most important decision of his life, to continue or not. How did I get this invite? I heard him whisper to his wife of 50 years, “Well, honey, I will miss you.”
Then, there was no beginning, middle, nor end. Time just stood still, and we were flashed into 50 years together -- hopes and dreams, weddings, sunsets, graduations, holidays, good times and bad. The lady immediately gave this half-naked man a full hug, and then, he reached for me next. “Oh, please, please, no tears. Just do the hug and leave or they will see you,” I thought.
He embraced his wife again. I looked to the floor and I turned to go, but I just couldn’t. All of the astronomical issues that I came to work with: my enormous grocery shopping list, the call to the plumber, the 7pm yoga class I was determined to make no matter what, vanished.
When we get to make it to the end so many times, it starts to set in. They say nothing matters in the end.
There are other instances if you don’t respond to the invite, no one will. There was a gentleman whom I took care of several years ago and when I went up to his hospital bed in the end, it was just us.
I met him in the outpatient clinic, and he always came alone to his daily radiation treatments. His social history was one of fame and fortune in his youth, which was hard to believe in the end. Sometimes circumstances in the end don’t look like they did in the beginning or middle.
That night, it was myself, him, and the other dealings of the old portion of the hospital. I looked into the bed and saw a frail older man, but he probably was the cutest little baby in the beginning with a room full of people. In the middle, likely a dashing strong man with a family and fulfilling the American dream. And, now, at the end, he was a quiet person fighting back the pain with morphine and unable to say hello or recollect my name.
At the end, it can be difficult, for both of us. The end for the patient is not always the end for us. We take it home, it gets into our dreams, affects our personal relationships and interactions.
We remember the end far too much. “What could I have done differently?” We reflect upon the middle and try to engineer mishaps that occurred, wrong decisions made, all in an effort to avoid the end.
My dear friend is a hospitalist, and when on night duty and a patient dies in the hospital, she has to visit and pronounce them deceased. She stops by the room and does a small moment of silence. The grand privilege about oncology is that we don’t usually need to be called in, or paged, or invited to come in at the end.
Oncologists and the end go hand in hand. People always tell me, “the end is the most important; everything with a beginning has to have an end.” So, no need to rush, or be stressed to get there on time, by being an oncologist, you are privileged to be included right in the middle…of the end.