Privileged #1 - How are you?

One of my most memorable patients was a wonderful lady with floridly metastatic, unresponsive to treatment, triple negative breast cancer who developed subsequent cardiomyopathy from chemotherapy. She had an EF of <10% and during the course of her hospitalization underwent multi-organ system failure from end organ ischemia. To translate this into normal speak: she had the worst possible breast cancer, with the worst possible response to treatment, and the worst possible side effects.

I was only an intern but I had to give 'the talk.' I sat her family in a conference room, went through the facts of her case slowly, and gave my assessment: she had two terminal conditions, both of which we could not fix. The family cried, and the oncologist piped up about radiation, or another round of chemo if we could get her heart back, or something ridiculous. I ignored him completely. I sat there for five painful minutes while they cried and asked me "Why?!" Once you have done this a few times, you realize that as much as a family wants the answer, you do not have it. Bad luck? Fate? God's will? There is no right answer to this question, only tissues and holding a hand.

The family consented to weaning off vasopressors (medications to elevate blood pressure), and with her loved ones at her bedside, we turned off all the supportive measures. I declared her dead about 30 minutes later. As memorable a moment as this was, it was not the most memorable.

The privileged moment came one day earlier. The oncology attending had just met with the family and discussed keeping their hopes up as well as future chemo options. It was a pep rally, to be sure. I was eating lunch at the time. My senior resident asked me to check on the labs, so I headed back to the ICU, and ran into the patient's sister in the hallway. I said, "Hi! How are you?" with a little wave.

She looked at me, and managed say, "I'm fine, tha-" before bursting into tears. She collapsed to her knees in the hallway, and I had to help her into a chair. I got her some tissues and sat with her for 15 minutes. We joked a little about some funny things her sister had said. After regaining her composure, she looked at me directly, and asked, "Dr ifinding, is she going to die?" I told her that we should get her family together and talk about this, leading to the family meeting the next day.

I am still amazed that this small, chance event of saying hello could be so profound. It was the opening she sought, the chance to ask the question everyone had avoided. She just needed a chance to ask. And it made me realize that even the smallest interactions can have big impacts.

I also felt very honored by the trust placed in me by this family. I was the wet-behind-the-ears intern, but they saw me every morning doing my job, and that was enough for them, because being a good doctor means that you are someone worthy of trust.

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