An unexpected visit

Returning phone calls isn't my strong suit. I'm not sure what it is, but I'd rather just take the calls as they come, whenever possible. I usually let my patients know to have me paged if they need anything important, so it's not unusual for me to hear from my patients at odd times. It's a bit more unusual for me to have patients show up at the office without an appointment. I always squeeze people in if they call, but it's a little harder if they just walk in (and the staff hates it---I guess it throws them off their game). So when Mr. Y showed up one morning, it was a bit of a surprise.

He's a fairly new patient, a real nice older guy, the kind of guy who might not love coming to doctors but always has a firm handshake and a smile for me. He's got some chronic lung disease, so he can't always breath well, but he loves to play sports, even in the winter (albeit rather slowly). Sometimes he complains about his breathing, and I try to help him out, but he knows that his past smoking pretty well did away with his lungs, so he gets by with what he's got.

He normally wouldn't bother to see me about some mild shortness of breath, but one day he came in complaining about it, and mentioned that he had also coughed up some blood. This isn't too unusual with bronchitis or heart failure, and he was taking a blood thinner, but something about his story bothered me. I got an X-ray, which confirmed that he has crappy lungs, but I was still very suspicious, so I had him get a CT scan right away. The results weren't good.

I got him to a specialist right away, but there wasn't much to offer him. Every bit of his lungs that hadn't already been destroyed by smoking was filled with cancer. Given his overall health, he wasn't going to do well with chemotherapy, and he knew it.

Still, it was a surprise when he walked into the office unannounced. My staff knew about his diagnosis, and asked me what they should do. I had them bring him back to a room. He was painfully apologetic.

"Doc, I'm really sorry to just barge in like this."

I reassured him that it was no bother. We sat and chatted for a while. He explained that he knew what was coming as was prepared. He and his family had spoken, he put his affairs in order, and he felt ready for whatever was coming.

"Doc, can I still play softball?"

"Could you play it yesterday?" I asked.

"Sure," he said with big grin.

"Well then, why not tomorrow and the next day, until you just can't do it anymore? You're the same person you were yesterday, except for knowing you have a crappy disease."

"I really shouldn't take up more of your time. I can see there's a lot of people waiting, and they probably need to see the doctor," he said, not rushing to get up. "You probably have more important things to do."

I looked up at him. "There is nothing more important than what I am doing right here, right now. You are welcome in my office any time. You know that, right?"

With that he rose and shook my hand. "Alright, Doc, I guess I'll see you later then, OK?"

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Ouch. Too close to home. My dad could have been Mr. Y, except:

* On Jan 29, he was diagnosed with lung cancer that had metastasized to his liver and given 3 months to live. On Feb 4 (yeah, yesterday), he passed away.


* My dad lives in a place in the US where doctors are leaving because they can't afford to treat patients due to low insurance reimbursement rates by the major insurance provider for the state. As a result, there are few specialists and waiting times for procedures such as biopsies are measured in weeks.

And drop-in visits like you describe? Not an option. Would've been nice, as he might have gone to the doctor sooner.

Wish I could blame someone.


By Theobroma Cacao (not verified) on 05 Feb 2009 #permalink

I'm sorry, I can't help myself. Has your patient been seen by an oncologist at a research institute with specialists in lung cancer? I'm wondering if he might benefit from something very tolerable like one of the anti-angiogenesis meds (though with that kind of central tumor and hemoptysis maybe not) or a TKI like erlotinib? Would he be interested in/qualified for any clinical trials?

I know, I know: not the point of the post, the patient's made the decision that's right for him, I don't know him, etc. But I hate doing nothing. It's a skill that every doctor has to have because sometimes there simply is nothing to be done and attempts to intervene could cause harm. But it doesn't come naturally to me.

@Dianne, I have heard your side and I respect it. However, if you offer me a slightly, longer life at great expense and inconvenience, it is not for me. There are people who are satisfied with their lives and they don't need to clutch at it.

Diane, I'm with Joe. Death isn't the capital-E Enemy, to be battled to the bitter end.

It's just the end of the book, and one of the best ways to wreck a really good story (or TV series, for that matter) is to keep tacking on chapters after its time to put 30 to it.

Be damned if I jump the shark.

I'm reasonably young (not yet 60) and in quite good health -- but I also have some extremely strict directives in place and have made my wishes very clear to my family and loved ones. I hope to die an embarrassment to them all, surrounded by great-grandchildren muffling giggles while telling stories about me -- but I want it to be on my terms, ideally propped up to watch another sunset over the Rio Grande.

Not staring at the ceiling in a hospital hooked up to so much equipment that they have to turn it off to know if I'm still there (and yes, that's what happened to my father.)

By D. C. Sessions (not verified) on 06 Feb 2009 #permalink

I really have two items here.

The first is a question -- in a situation such as this, presuming that the cancer hasn't metastasized, is it possible to do a bilateral lung transplant, or would the complications of chemotherapy and immunosuppressives be too much for most people to handle?

The other point is an observation. I have an uncle with advanced Huntington's disease. Several years ago he moved in with us and within a year attempted suicide (I accompanied him to the hospital while my sister cleaned up the mess). At the time he was still somewhat functional as a human being and I encouraged him at the time to make the best of what little quality time he had left. (Unfortunately, he has frittered most of that time away, and what is left of his personality and intellect is highly unpleasant and hard to manage.)

I hope that I'll be as ... content? when I have to go.

My mother died from lungcancer and I still blame myself (occasionally) for not being able to do more for her. And I guess I blame the doctors and hospitals for not paying more attention to her - but for what? Would a few more months have done her any good? She said, herself, that had she known it was gonna be like that, she'd never have stopped smoking and just dropped dead one day. (She stopped August 2006, started coughing blood in October, I think, and was diagnosed with first COLS and then after the first hospitalisation with cancer.)

Thank you for that moving post. We all have to die and being able to face it for ourselves and with each other is a skill we could stand help with cultivating.

You, sir, are a good doctor and a better human being. I know it's really hard for doctors to deal with the time when the quiver's empty and there's nothing more medicine can do for your patient. But that is precisely the time your humanity, rather than your skills, can make all the difference.

Writing the last chapter is hard for everyone. But it's much easier when your personal physician (what blessed words those can be) walks the last mile with you as a friend.

Don't underestimate the gift you've given to your patient and to his family. They will remember you with affection and gratitude forever.

By Leigh Williams (not verified) on 08 Feb 2009 #permalink

Just catching up on my reading after the weekend - this is beautiful, Doc. You're a good man.