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Melancholy

Melancholy It is late fall in New England. Flocks of geese race southward. Fallen leaves eddy at the roadside. The sun's oblique rays are barely warm. I am driving to my office from the home of Mary Emanuel, a 74-year-old woman who has stomach cancer. Upon being diagnosed one year ago, Mary dutifully agreed to surgery, chemotherapy, and radiation. She now, however, has bulky abdominal metastases, is losing weight, and feels weak and ill. I visited Mary to tell her she was dying. Such conversations ought to be had in person. Recently admitted to the hospital with a small-bowel obstruction, Mary was so cheerful with the staff, remaining warm and pleasant despite her pain, that none of her physicians would disclose to her the true extent of her disease. No one, I was later told, wanted to “rob her of hope.” Mary is the type of person who would elicit this response. One of the kindest women I have known, she considers it rude to visit my office without bringing a gift, and no matter how ill she feels, she first asks after my family before sharing her own concerns. Sitting with Mary, her husband and daughter nearby, I tell her the tumor has spread. Mary visibly deflates. She is a beautiful woman—someone who effortlessly glows—yet as she gazes down at the coffee table and whispers, “I thought I’d have more time,” she seems small, sallow, and defeated. Her husband tentatively reaches to peel apart her clasped hands while her daughter hugs her and weeps. I feel certain that despite being surrounded by loving family, Mary must never have felt more lonesome. Earlier in my career, delivering bad news seemed like a technical challenge. I would methodically seat patients and their family members facing one another, pause for a moment after reporting that there was an “unexpected finding” on a scan, and search for an opportunity to say that I “wish things were different”1 and that I would be there to help until the very end. This routine, though slightly stiff, helped anchor me in whatever emotional swell was to come. Now, however, these conversations just make me sad. Is my patient afraid of dying? Nothing I offer will quell that horrid fear. How will her surviving spouse get on? Some of them don't even know where the checkbook is kept, and most haven't been single since adolescence. Did I miss an opportunity for early diagnosis that could have saved her life? Hopefully not, but end-of-life discussions always force me to question my own competence. And how do we physicians manage the loss of long-standing patients, some of whom have become dear friends? One week later, I am visited by a 58-year-old woman with back pain. Susan Thomas has been my patient for four years, yet I don't know her well. Diagnosed with advanced ovarian cancer just before we met, Susan has seen a great deal of her oncologist, radiation oncologist, and surgeons but very little of me. I have noted and filed her consult notes, visited her during hospital stays, and called her every six months simply to check in, but I have largely been a bystander in her care. Susan had recently stopped by my office unannounced. In the neighborhood for a job interview, she had wanted to thank me in person for a telephone message I had left for her. Her visit had been deeply moving. I had never seen Susan “well.” At each of our previous appointments, she had been bloated from medications, chronically fatigued, with limp hair either falling out or growing back. That day, however, she had looked stunning. Her smart navy business suit had accentuated her newly toned body, her shoulder-length hair was thick and buoyant, and she had exuded a near-palpable vitality. Witnessing Susan's transition from illness to health and her desire to look her best after years of feeling ill had been authentically joyful. But today I am moved for other reasons. Susan has had low back pain for two months, becoming more severe over the past three days, has begun feeling numb between her legs, and recently lost her urine on the way to the bathroom. On examination her right hip flexors are weak. I send her to the hospital for emergency magnetic resonance imaging and when I arrive there that evening am told she has a three-centimeter mass at the base of her spinal cord and that her nearby nerve roots are coated with tumor. I sit with Susan to discuss these findings. Susan has sadly become accustomed to receiving bad news. No one is treated for ovarian cancer without enduring a series of difficult discussions. Yet the cry of “No!” she lets loose upon hearing of her condition speaks to fresh terror and vulnerability. It is a terrible thing to witness. Driving home that evening, I want nothing but a stiff drink. My life partner specializes in spinal cord injury medicine. He shoulders the stories and sorrows of people who have lost liberties most of us take for granted. They sometimes keep him awake at night. For my friends in oncology, suffering and setbacks are daily experiences. A general surgeon I have known and respected for years recently asked his department chair to remove him from the trauma call schedule. So unnerved by caring for the young survivor of a drive-by shooting, he had begun having flashbacks and nightmares. I love practicing medicine. Unequivocally. Yet it sometimes seems as much a burden as a privilege. We begin our careers in the anatomy room, a ghoulish lab in which many “civilians” would faint. We cut our teeth in bloody operating rooms and intensive care units from which few people leave intact. We spend our lives bearing witness to the sufferings and diseases of troubled souls. We are well paid, intellectually stimulated, and, if we are lucky, trusted and maybe even loved by our patients. Yet on certain days, when our patients do not do well, the trade-off seems untenable. How are we to protect ourselves from the emotional hazards of the practice of medicine? How are we to stand with our patients through the very worst while avoiding depression, significant stress reactions, and even substance abuse or addiction? Withdrawal is not an option. When patients become seriously ill, they expect to have a physician whom they can trust and who will help them make sensible and appropriate decisions. Such relationships are usually built over time, sometimes through heroic interventions, but more generally at routine office visits, through consideration shown, and with promptly returned phone calls. Yet they fundamentally rely on personal and emotional engagement and investment. There is simply no way to be a good but distant physician. Perhaps the answer is to recognize and appreciate joyful moments and to allow their accumulated bulk to outweigh the horrors. To try to focus on the triumph that Mary will die—precisely as she has chosen—in her own bedroom rather than on an operating table; on her good fortune to have a family not simply willing but eager to put aside their own responsibilities to care for her at home. Are we able to find solace in Susan's respite from her illness, during which she was able to look and feel so vital and well? Back to top Article Information Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Acknowledgment: The names of the patients are fictitious; their stories are not. The author is grateful for permission to publish them. References 1. Quill TE, Arnold RM, Platt F. “I wish things were different”: expressing wishes in response to loss, futility, and unrealistic hopes. Ann Intern Med. 2001;135(7):551-555Google ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Melancholy

JAMA , Volume 305 (13) – Apr 6, 2011

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References (1)

Publisher
American Medical Association
Copyright
Copyright © 2011 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.2011.364
Publisher site
See Article on Publisher Site

Abstract

It is late fall in New England. Flocks of geese race southward. Fallen leaves eddy at the roadside. The sun's oblique rays are barely warm. I am driving to my office from the home of Mary Emanuel, a 74-year-old woman who has stomach cancer. Upon being diagnosed one year ago, Mary dutifully agreed to surgery, chemotherapy, and radiation. She now, however, has bulky abdominal metastases, is losing weight, and feels weak and ill. I visited Mary to tell her she was dying. Such conversations ought to be had in person. Recently admitted to the hospital with a small-bowel obstruction, Mary was so cheerful with the staff, remaining warm and pleasant despite her pain, that none of her physicians would disclose to her the true extent of her disease. No one, I was later told, wanted to “rob her of hope.” Mary is the type of person who would elicit this response. One of the kindest women I have known, she considers it rude to visit my office without bringing a gift, and no matter how ill she feels, she first asks after my family before sharing her own concerns. Sitting with Mary, her husband and daughter nearby, I tell her the tumor has spread. Mary visibly deflates. She is a beautiful woman—someone who effortlessly glows—yet as she gazes down at the coffee table and whispers, “I thought I’d have more time,” she seems small, sallow, and defeated. Her husband tentatively reaches to peel apart her clasped hands while her daughter hugs her and weeps. I feel certain that despite being surrounded by loving family, Mary must never have felt more lonesome. Earlier in my career, delivering bad news seemed like a technical challenge. I would methodically seat patients and their family members facing one another, pause for a moment after reporting that there was an “unexpected finding” on a scan, and search for an opportunity to say that I “wish things were different”1 and that I would be there to help until the very end. This routine, though slightly stiff, helped anchor me in whatever emotional swell was to come. Now, however, these conversations just make me sad. Is my patient afraid of dying? Nothing I offer will quell that horrid fear. How will her surviving spouse get on? Some of them don't even know where the checkbook is kept, and most haven't been single since adolescence. Did I miss an opportunity for early diagnosis that could have saved her life? Hopefully not, but end-of-life discussions always force me to question my own competence. And how do we physicians manage the loss of long-standing patients, some of whom have become dear friends? One week later, I am visited by a 58-year-old woman with back pain. Susan Thomas has been my patient for four years, yet I don't know her well. Diagnosed with advanced ovarian cancer just before we met, Susan has seen a great deal of her oncologist, radiation oncologist, and surgeons but very little of me. I have noted and filed her consult notes, visited her during hospital stays, and called her every six months simply to check in, but I have largely been a bystander in her care. Susan had recently stopped by my office unannounced. In the neighborhood for a job interview, she had wanted to thank me in person for a telephone message I had left for her. Her visit had been deeply moving. I had never seen Susan “well.” At each of our previous appointments, she had been bloated from medications, chronically fatigued, with limp hair either falling out or growing back. That day, however, she had looked stunning. Her smart navy business suit had accentuated her newly toned body, her shoulder-length hair was thick and buoyant, and she had exuded a near-palpable vitality. Witnessing Susan's transition from illness to health and her desire to look her best after years of feeling ill had been authentically joyful. But today I am moved for other reasons. Susan has had low back pain for two months, becoming more severe over the past three days, has begun feeling numb between her legs, and recently lost her urine on the way to the bathroom. On examination her right hip flexors are weak. I send her to the hospital for emergency magnetic resonance imaging and when I arrive there that evening am told she has a three-centimeter mass at the base of her spinal cord and that her nearby nerve roots are coated with tumor. I sit with Susan to discuss these findings. Susan has sadly become accustomed to receiving bad news. No one is treated for ovarian cancer without enduring a series of difficult discussions. Yet the cry of “No!” she lets loose upon hearing of her condition speaks to fresh terror and vulnerability. It is a terrible thing to witness. Driving home that evening, I want nothing but a stiff drink. My life partner specializes in spinal cord injury medicine. He shoulders the stories and sorrows of people who have lost liberties most of us take for granted. They sometimes keep him awake at night. For my friends in oncology, suffering and setbacks are daily experiences. A general surgeon I have known and respected for years recently asked his department chair to remove him from the trauma call schedule. So unnerved by caring for the young survivor of a drive-by shooting, he had begun having flashbacks and nightmares. I love practicing medicine. Unequivocally. Yet it sometimes seems as much a burden as a privilege. We begin our careers in the anatomy room, a ghoulish lab in which many “civilians” would faint. We cut our teeth in bloody operating rooms and intensive care units from which few people leave intact. We spend our lives bearing witness to the sufferings and diseases of troubled souls. We are well paid, intellectually stimulated, and, if we are lucky, trusted and maybe even loved by our patients. Yet on certain days, when our patients do not do well, the trade-off seems untenable. How are we to protect ourselves from the emotional hazards of the practice of medicine? How are we to stand with our patients through the very worst while avoiding depression, significant stress reactions, and even substance abuse or addiction? Withdrawal is not an option. When patients become seriously ill, they expect to have a physician whom they can trust and who will help them make sensible and appropriate decisions. Such relationships are usually built over time, sometimes through heroic interventions, but more generally at routine office visits, through consideration shown, and with promptly returned phone calls. Yet they fundamentally rely on personal and emotional engagement and investment. There is simply no way to be a good but distant physician. Perhaps the answer is to recognize and appreciate joyful moments and to allow their accumulated bulk to outweigh the horrors. To try to focus on the triumph that Mary will die—precisely as she has chosen—in her own bedroom rather than on an operating table; on her good fortune to have a family not simply willing but eager to put aside their own responsibilities to care for her at home. Are we able to find solace in Susan's respite from her illness, during which she was able to look and feel so vital and well? Back to top Article Information Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Acknowledgment: The names of the patients are fictitious; their stories are not. The author is grateful for permission to publish them. References 1. Quill TE, Arnold RM, Platt F. “I wish things were different”: expressing wishes in response to loss, futility, and unrealistic hopes. Ann Intern Med. 2001;135(7):551-555Google ScholarCrossref

Journal

JAMAAmerican Medical Association

Published: Apr 6, 2011

There are no references for this article.