Monday, April 4, 2011

The saddest rounds

Today's rounds were the saddest I've ever been a part of.

Mrs. R has tracheal cancer. It is metastatic and terminal. She's received treatment already- a trach tube, chemotherapy- and there is no more that we can offer her. She can't speak, so she writes, whenever there is something more complicated than can be communicated with a nod or a gesture. Her level of education is low, and she writes in all capital letters, and mis-spells words- which somehow makes thing even more poignant. Something about those few words in large capital letters, a few letters swapped here and there, seems very urgent, very desperate. We ask her how she's doing, and she shakes her head.
"What is it, Mrs. R? What's wrong?"
I push over the pen and paper, and lower the table so she can write to us.
"You tried to call your nurse? You needed something?"
We apologize, we try to reassure Mrs. R that we will do everything we can to make sure she's comfortable. She had had trouble breathing last night, and nursing reports this morning were of liquid tube feedings oozing out around her trach site-- not a good sign, and not something you'd want to happen to a woman receiving "comfort care". Suffocating on your food is far from comfortable. In fact, we discuss in the hall, what may be best for Mrs. R's comfort right now is to stop the tube feeds altogether. Which is a dismal thought, but indeed perhaps better than a death due to choking on liquid feeding formula.

From there we go upstairs to visit Mr. M. Mr. M has bladder cancer that obstructs his urinary tract, and for which the only treatment is surgery. Which he cannot have, because his heart is not strong enough to survive it. He has been on our service for weeks, first while we negotiated with the surgery team whether there wasn't some way to get Mr. M the only surgery that would save his life- and then, when that failed, to arrange for hospice placement. Today we have good news: there is a bed for him at a small facility run by nuns, that the social worker assures us is lovely.

When we walk in the room, a chaplain is sitting on the edge of Mr. M's bed, and I can tell by his body language that they have gotten to know each other well over the last few weeks. We tell Mr. M the good news. It's hard to hear his response because he speaks softly and has no teeth, so we are all leaning forward. The resident is about to answer the question he thinks was asked, which is, "How long do I have to live?" when the chaplain corrects him.

"No, he said, 'how long will the rehabilitation be?'"

We look at each other, a little panicked. The resident wants to be straightforward, to convey to the patient what everyone else in the room understands and accepts, because it is not our life's end that we are discussing, and it is much easier to avoid denial when it is someone else's death. But he also does not want to be blunt and heartless; he wants to maintain good rapport with his patient. And so he dances around his words a little. Not enough to seem dishonest; but enough to seem a little uncomfortable, which to me is reassuring: seamlessness when discussing the end of a patient's life betrays overconfidence, or something worse.

"Mr. M, what we want you to understand is that this cancer that you have, we think it's the thing that... that will ultimately be the cause of your death."

More questions from Mr. M., increasingly desperate: Why can't I have the operation? Why didn't they find my cancer sooner? Why can't you just take the tubes out and let me be?

"Mr. M," the resident continues, still trying to find the right mix of straightforward and comforting, "you need to understand that if we take those tubes out, you'll... you'll pass away in the next few days."

Mr. M is struck silent, finally tells us that he wants to be alone, and we walk out. We talk about the difficulty in accepting an approach that does not have cure as its objective, and the necessity of explaining the same thing several times over, of not assuming the patient is at the same stage of acceptance that you are. We write our orders and move on to the next patient, because there's no time in the middle of rounds to linger on sadness.


R Family said...

I can't even imagine how helpless an experience like that must make you feel.

It seems weird to say this based on the content, but this is beautifully written.

Rica said...

Thanks! I appreciate the comment (and am reminded to visit your blog!). And don't worry, not every day is like this. But the ones that are are pretty tough.

MissChai said...
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