Case: Metastatic Cancer Week

Sometimes when I'm the hospitalist it seems as though most of the patients have the same disease or symptom. I call these Theme Weeks. Middle of winter usually features Shortness of Breath Week, but sometimes we have Skin-Popping Abscess Week or Young Men with Rhabdo Week. Around the holidays we also get Suicide Attempt Gone Awry Week. Most of the time, I find Theme Weeks amusing, in a dark way, but sometimes they are sad and wonderful, as they were during the Metastatic Cancer Week I had not long ago.

On the service that week I had Mr. P, who had advanced prostate cancer with bony metastases and who was really admitted to die. Hospice cared for him at home, but his pain was unmanageable on oral medications. In the hospital we put him on a morphine PCA with a generous basal rate but still he suffered. When I walked on to the service, I could hear him cry out in pain, and when I peeked into his room I saw he was trembling. I saw the orders to increase the PCA were very stingy and I changed them. Fortunately, Lily was Mr. P's nurse that day, and she'd done a lot of home hospice before returning to hospital nursing. "Take the basal rate on the PCA and double it every hour if you need to until he looks comfortable," I said. She gave me a nod and got right to it.

I read my list and saw that, down the next hallway, I had Mr. G who had metastatic colon cancer. What, two cases of advanced cancer on the service? You have to understand, we're a tiny community hospital, not a big cancer referral center, so we don't automatically have cancer patients on our service every day. To have two cancer patients at the same time is unusual, and even more so when both have advanced disease.

When I opened Mr. G's chart, I was afraid to find the same story as Mr. P: admitted for intractable pain. It was something bordering on relief to find that he'd been admitted early that morning with shortness of breath and pleuritic chest pain. A D-Dimer had been ordered and was markedly elevated at greater than 5000. Lower extremity Dopplers had been done and the preliminary reading on the chart said Mr. G had extensive deep vein thromboses from the popliteal vein up to the mid-femoral region. The ER doctor suspected a pulmonary embolism and had started Mr. G on low molecular-weight heparin (LMWH), even though a chest CT had not been done. Certainly Mr. G was at high risk for thromboembolic disease, given his history of cancer, and with the verification of lower extremity disease I didn't feel a chest CT was necessary. I could proceed with anticoagulation with warfarin, using LMWH as a bridge therapy.

I went into Mr. G's room to introduce myself. Unlike Mr. P, who was wasted away from his disease, Mr. G was burly and robust-looking. He had adenocarcinoma originating in his colon and known metastases to the lung and liver, but was receiving palliative chemotherapy to keep the cancer in check. He'd just finished a four-week round of chemo and was at the beginning of a two-week cycle off. I commented on what a bummer it must be to end up in the hospital during his weeks off.

Mr. G shrugged. "It's not so bad," he said. "I'd rather be here than going through this at home." He was a distinguished-looking African-American man with greying hair and a merry expression. When he spoke to me, I felt the weight of his welcome and attention. "So, what can you tell me, Dr. Chan?"

I explained to him the presumptive diagnosis of a pulmonary embolism, of the known presence of lower extremity thrombosis, and the association of cancer with thromboembolic disease. I explained that I didn't think a CT of the chest was necessary, that the likelihood this was a PE was high, but if he wanted to be sure I would order the study. The one advantage to doing a CT would be to put the icing on the diagnosis before he got loaded on warfarin.

Mr. G thought about it. "I get CAT scans every few months, for the cancer," he said. "I don't really want another one if you think it's likely I have this--what did you call it? Blood clot?

"Correct. You've got a good memory."

He smiled weakly. "I used to be in sales. I had to have a good memory," he said. Then he laid his head back on his pillow and looked out the window for a moment. When he turned back to me, he said "Will I get over this, Dr. Chan?" His gaze was forthright and resigned, the look of a man who is used to hearing the worst without flinching.

I chose my words carefully. "I think you're going to get better from the blood clot," I said. "I think if we give you blood thinners and keep you in the hospital until they reach the right level in your blood, you won't feel as breathless and that pain in your side will go away. So, yes, you are going to get over this blood clot. The clot is treatable. But I can't say this will never happen again, because you have cancer, and cancer makes this kind of clot more likely. I'll have to talk to your oncologist, but you're probably going to have to take some kind of blood thinner from now on."

He smiled at me brilliantly. "I can do that," he said. "I can thin my blood if it means I can feel pretty good most days." He and his wife had been hiking in Europe only six months before, during another break in chemo. He liked to attend his grandson's football games on weekends, and to listen to his wife sing in their church choir. Taking warfarin every day, getting his prothrombin time checked every week--that was nothing.

When I excused myself, he took me by the hand. "Thank you, Dr. Chan," he said. "Thank you for telling me good news."

Was it good news? I wondered. Was it good news to tell a man he had a predictable complication of cancer, no matter how stable his condition was? I didn't know. The problem is, when someone has an incurable disease, you don't know when the downward spiral begins. I really didn't want this to be the beginning of Mr. G's end.

I had a big service to round on, so Mr. G's problems took their place lower on my priority list as I discharged some patients, admitted others, worked up diagnoses, talked to consultants. Mr. P's pain required constant surveillance. I got the morphine PCA up to 40mg per hour and got the anesthesiologist involved. By the end of the day I had the satisfaction of seeing him rest more easily.

The next day, I peeked into Mr. P's room. He was well-medicated at last, and although semi-wakeful, had that far-away look on his face that actively dying patients sometimes get. Lily was working with him again. "His ears are getting flat," she told me. "Their ears always flatten against their heads when they're getting close, something to do with muscle tone." This is old-school country hospice nursing lore, and it is worth its weight in gold. I will happily overlook flat ears every day for the rest of my life as long as there are nurses like Lily, who took such excellent care of Mr. P that he never once suffered from dirty linen, dry mouth, or prolonged immobility in the same position.

I had to round on a half-dozen other patients before I could make my way to Mr. G. As I flipped through his chart I realized I was looking forward to talking to him again. Some patients are like that; you hardly notice the time passing when you talk with them, and after leaving their rooms, the rest of your job is so much more bearable.

I found Mr. G watching college football with his wife. "How are you, Dr. Chan?" he asked, and introduced me to Mrs. G. He looked better than the day before, much more relaxed. I explained to him that his prothrombin time wasn't high enough yet and he'd have to stay in the hospital for LMWH another day or so until it rose. I reassured him that his clot was probably starting to resolve already, because he was already breathing easier and the pleuritic pain was minimal.

"I'm not worried," he said. "Ever since you came in and gave me the good news yesterday, I have nothing to worry about. Anyway, this cancer, it's taught me one thing: It does no good to worry. You can't control how things turn out, so what's the point of worrying? I never worry about anything anymore."

"Well," said Mrs. G. "He doesn't worry most of the time, anyway." She looked wryly at her husband, then at me. She gestured toward him. "That's the love of my life, you know," she told me.

Do you ever feel tears welling up in your eyes when you're on the job? Do you find yourself sniffing discreetly and clearing your throat when something wonderful and poignant and awe-inspiring happens? I do. I'm the biggest bawler on the medical staff and you can broadcast the fact from the rooftops. It is the greatest gift I possess, this leaf-like capacity to be moved, because it opens up the world to me. I wouldn't trade it for a month at Disneyland.

Later that day, Mr. P died peacefully and Mr. G went for a walk outside the building with the love of his life. I call that a good day. We do good work up here in Rural.

Comments

[Tami]

Thank you for taking time to share this story.

My father died of metastatic colon/liver cancer 9 years ago and I am so thankful that his hospice nurse was 'brave' enough to get an increase in his PO morphine so that later that night when he died he went in peace instead of agonizing pain.

[flo]

Mmmmh, I'm sure you do good work, but I'd like to know how you keep going, or even keep work and private life separate when you are always so moved? I'm pretty sure that I couldn't keep up with that, so I'm glad I can keep my distance to patients, sure I'm nice to them, but in a "I'd mourn for them" way ... just see too many for that I think.

[flo]

should have been:*not in a "I'd mourn or them" way

[CancerDoc]

Sometimes, people ask me how I do what I do, and on some days, I don't know. I am glad that you see the people behind the diagnoses: the man who needs to die in peace, the love affair that will continue. For some reason, many in health care find it difficult to be around the dying cancer patient. I still haven't figured that one out. The people behind the cancer are the reason that I feel privileged to be a part of the journey, even when the journey ends in death.

[Maggie]

A couple of days ago an oncologist gave me some very bad news about my recently discovered cancer. I was aware that he was in emotional difficulty but so very much appreciated that, even so, he didn't flinch from complete honesty with me. In any crisis I tend not to be emotional, just very interested in learning all I can to resolve or mitigate or decide how I'll live with something, but I've always had a keen appreciation of those who are visibly easily touched by others' problems, as this doctor was. I am, too, as a matter of fact, but usually tuck the emotions away completely as I try to figure out how I can help. I am concerned that in this area to which I've recently moved there seems to be a great reluctance among the medical community to prescribe effective doses of effective pain killers. I've never needed them in my long life, but suspect I will be longing for them very shortly.

[rlbates]

Nothing to add to the above comments. I enjoy your stories. Thanks