As a recent graduate, I have found medical practice to be more complex than I ever imagined. With no one checking my work, I have no one to answer to except my patients. It is easy to learn about breaking bad news; it is another thing to do it. I was unprepared for the emotional impact it would have on me. Having a connection with a person makes this difficult task even more challenging. Leo Thompson (not his real name) taught me this valuable lesson.
Our journey started on a Friday when he came to my office. My back hurts a bit, Doc.
To my surprise my patient had saddle anesthesia. It is hard enough to get a computed tomography scan outside a tertiary centre; try getting one on a Friday afternoon. No one believed my assessment that Leo needed the scan urgently. Red tape is infuriating. I needed to talk to The Man
who controlled the access. I needed to persuade him.
Leo and I needed answers.
Monday afternoon the report arrived. A mass in his lumbar region was compressing Leo's spine. More tests were required. It became a seemingly endless journey for answers.
Tuesday was my day of reckoning. We had to talk about the mass his CT had revealed. I was torn. My heart wanted to protect him from the harsh truth, but my mind knew he needed to know. It is difficult to decide what to tell patients. We walk a tightrope between needlessly burdening patients and giving them true autonomy. Leo was up front and wanted to know if the mass was cancer. We discussed all the possibilities including the dreaded C
word. It was too early to make any diagnoses, but further tests would tell us more.
Leo had metastatic cancer. Colon cancer, which had metastasized to his liver, lungs, ribs, scapula, hip, and sacrum, was eating away at his body. A cure was inconceivable because the cancer already coursed through his body. I was sad and anxious. Was I ready for this? Had school given me the tools I needed for myself and for Leo? I had no idea what to say or do.
Leo and his wife came in together. The look in their eyes showed they knew something
was wrong. His wife was especially frightened, but Leo put on a brave face. I got tears in my eyes. In a soft voice, on the edge of breaking, I told him he had metastatic cancer. There was no cure. What could I tell him to ease his mind? Nothing. How did he respond to my tragic news? Them's the breaks, Doc. I have always tried to eat and live healthy, but I guess I should have partied more instead.
He was being funny as his wife and I fought back our tears. We were supposed to be supporting him, but instead he bravely supported us. Fighting for composure, I struggled to find my self
between person and healer. All the teaching and role playing had not prepared me for the emotion I felt in that moment. It overwhelmed me. It overcame me.
Had he seen my tears? I hoped not; I did not want to be perceived as weak, but hiding emotions is not my strong suit. He later admitted he had seen through me. Eyes are the window to the soul, after all.
Discussing how he and his family were coping, we talked about his difficulty in telling them. His support for me appeared once again. That was your first time wasn't it?
he asked. I did not need to answer him; he knew. Even though you were upset and teary, you did a good job.
Even now he tried to help me, tried to ease my mind, tried to give me peace.
Our journey progressed. He saw several specialists at the regional cancer centre. He traveled often for his experimental chemotherapy, but it worked well, so he did not mind the journey. Our regular visits continued. He would drop in after all his appointments with the specialists so that I would be aware. I was someone outside his family to whom he could talk and from whom he could receive support.
We had a connection. We were each experiencing something new but from very different perspectives. Family was a frequent topic of conversation. His son's spring wedding was fast approaching. He reached his goal of making it to the big day.
Suddenly a bowel obstruction sent him to our small local hospital. A palliative colostomy was his only option. Fortunately, the surgery was uneventful and he recovered well. He was surrounded by fain- and friends.
Then one
night, after everyone had visited, he clutched his
chest and died of a massive myocardial infarction. His journey was over, but ours continued. His family was shocked and so was I. Leo's son, clutching his own baby, yelled at Leo's body. You can't leave us now. We weren't ready.
But Leo had been ready.
I know I'm going to die soon. I have the chance to make amends and say goodbye, to make sure that everything that needs to be said has been.
All of us had prepared ourselves for Leo's cancer to take him slowly. We had never imagined that he would go suddenly. A heart attack was furthest from our minds.
The gravity of :he situation gradually set in. I was sad, angry, and frustrated — I suspect only a fraction of what his family felt.
I will never forget Leo, the first patient who allowed me to travel with him on his journey through death and dying. I learned a lot about the true importance of the patient-doctor relationship. Sometimes it is not about the medicine that you provide, but the relationship itself: the ear to listen, the hand to hold, and the shoulder on which to cry.
Dr Parr is a rural family physician practising in Mount Brydges, Ont, and is an Assistant Professor in the Department of Family Medicine at the University of Western Ontario in London.
Acknowledgment
I thank Drs Jim and Leslie Rourke from the Rural Medicine and Health Course in the University of Western Ontario's Masters in Clinical Sciences Program for their support. I also thank Dr Ted Osmun for his support and guidance.
Taken from the Canadian Family Physician
April 2006