I didn’t get to say goodbye
A provider’s thoughts on death (part 2)
I think about you more often than you realize.
The silhouette of your body hunched over your walker, evidence of the pain that we are slowly losing control over.
Together we tiptoe the line between treating your cancer-induced pain with chemotherapy and opioids. Still the cancer grows, still the pain increases. Our resources are finite.
Despite it all, you smile.
Another biopsy, another blood transfusion, another lung infection, another line of treatment.
Still you thank me at the end of each visit. Even if there was nothing worthy of thanks aside from our sitting together — which I know counts for something.
And tonight, I think about you again. Because I didn’t get to say goodbye.
I’m often asked how I can work in oncology, where there are so many terminal diagnoses. And yes, it comes with many challenges. But I face death less than you think.
I chose this field because I saw value in learning to have honest, genuine, hard conversations. It takes courage to look a 34-year-old teacher and mother of 2 kids in the eyes and tell her she has metastatic colon cancer that cannot be cured. I do not enjoy talking about the prognosis, the fact that this will be her life defining illness, that she will die from this.
But.
I feel empowered to be upfront with these truths and hopefully deliver them with empathy and kindness. My patients deserve to hear the honest reality from someone who cares about them.
In this setting you would expect that when it came time for these patients to die, I would also be there for the discussion. But often I am not. And lately I have been wondering why.
You see, the actual decline into death is less anticipated than one might think. When it comes down to it, most people want to do every treatment possible to prolong their lives. And the more we study and find new medications to treat cancer, the more options there are to be tried.
When that CT scan shows progression of the cancer, letting us know the current treatment is no longer working, we discuss the next steps. This is, of course, patient specific.
While hospice is an option for individuals with 6 months or less to live, those who elect to continue trying treatment after treatment are less likely to choose this route during these discussions. Some just want to fight as long as they can. (Please note, there is no right or wrong decision here).
However, it is the natural course of cancer to form resistance to each new therapy. The amount of time this takes can vary. But once the cancer or side effects of treatment have overpowered the treatment effect, the last option is hospice. This involves managing symptoms and keeping the individual comfortable, without treating the cancer, until the end of their life — whenever that may be.
It often takes an inciting event to halt treatment in the individuals who want to try every available option. One day they are getting treatment with us in the clinic and then something changes over the weekend. They will end up in the hospital with acute kidney injury, infections like sepsis or pneumonia, uncontrolled pain.
And that’s it. They are unable to recover.
The hospital team or oncologists who are rounding on them will discuss the options. A hospice referral is placed and our clinic is notified that the patient “is on comfort cares.”
And I wish I could have hugged them goodbye.
While I am still processing these thoughts, I have 2 take-aways:
I want my patients to know hospice is an option, to tell them I support their choice to prioritize quality over quantity of life, if that is their wish. It takes a strong person to decide to stop treatment, just like it takes a tough person to continue.
Mostly I want to tell people how I feel about them. Cancer diagnosis or not, we don’t know how long we have with those around us.
So tell your people that you appreciate their quirky personality, their laughter brings you joy, they made a difference today, you’re happy doing life with them.
This week I plan to hug a few more patients than usual, because it will communicate more than even I might understand.
Thank you for being here,
Cheyenne
Good thoughts. Hug more people around us than we normally. Appreciate them in the moment.