A Hard Talk With a Hero, Bravely Facing the End of Life

A Hard Talk With a Hero, Bravely Facing the End of Life

Prateek Mendiratta, MD

@cancerdocinevo
May 08, 2017

Do you have a favorite superhero, someone who is willing to sacrifice themselves in order to help others? Imagine if you found out your superhero not only lived under the same roof, but was also your brother.

HBO Real Sports recently highlighted a true superhero and his brother in its profile of Lucas and Noah Aldrich. Lucas is unable to compete in triathlons due to a rare neurological disorder; Noah, his superhero, has found a way to overcome this obstacle. Noah, through help of his family and with an almost super-human ability, pulls Lucas in the water, on the bike, and on the race course to make sure they finish together as brothers. They don’t win any of the races, yet they are true champions when it comes to the game of life.

As an oncologist, I am also able to witness superheroes who display their super-human traits every day, from the patients battling against all odds to the caregivers who are there to sacrifice themselves to help them along the journey. Not every journey leads to a happy ending, but we don’t define our victories by cure. We define our victories by the quality of life we were able to provide for our patients. Two men came into my life very early in my oncology practice who taught me about the bond between brothers and the importance of always discussing the patient’s wishes about continuing treatment.

I met this particular patient in my Veteran Affairs clinic during my second month as a freshly minted fellow. For 55 years of his life, he had followed his own path. After his honorable service to our country in the army, he had worked as a chef, photographer, park ranger, and most recently was in a jazz band. He was not married and never had children, but he was not alone: his younger brother was by his side. My patient had been diagnosed with prostate cancer 5 years before and, after a prostatectomy, his PSA had begun to rise a year ago. His urologist started him on androgen deprivation to starve the cancer cells from their life source, testosterone. His PSA continued to rise after an initial response and the patient had now developed worsening back pain, abdominal pain, and weight loss. Unfortunately, the labs confirmed how sick he was and we needed to admit him to the hospital to manage his symptoms.

We ordered scans and got his pain under control. The tumors had invaded his liver and lymph nodes. One spot was impinging on his spinal cord, threatening his motor and sensory function. We had to act quickly and started him on steroids to quiet his spinal cord irritation. Next we started emergent radiation to attack and prevent the cancer cells from destroying the nerve fibers. During that whole hospital stay, his younger brother never left his side, even though he had a spouse and children of his own. That sibling bond was amazing to see. The brother told me, “He’s my hero and best friend growing up, so I always try to be there for him.”

My patient eventually got stronger and I saw him in the office, where we discussed options and laid out possible treatment plans. I asked him what his goals were. He wanted to fight his cancer and was ready to embark on the journey ahead. He would always look at his younger brother before answering my questions, reassuring me, “I can beat this, Doc.” His optimism was contagious. I explained how aggressive his disease was, yet never really explained the goals of therapy and the key difference between palliation and cure. We started him on an aggressive chemotherapy regimen. Together, the brothers battled every 3 weeks bravely and we were rewarded with a dramatic response. Six months later, the patient was pain free, with rapid improvement of his PSA and lesions on scans. We continued to follow him and he continued to live his life by his own rules. He moved in with his brother and they continued to build their bond. At every follow-up visit I would remark how great he was doing and their positive spirit rubbed off, and even I believed we had beaten his cancer.

Unfortunately, with time, the cancer knocked our optimism back to reality. His cancer returned with a vengeance and we continued different treatment options to keep it at bay. Treatment after treatment led to limited returns and the side effects of these therapies started to wither the spirit of my patient. With each successive treatment, his strength and will was beginning to falter. The patient’s brother never left his side, trying to will the cancer away. The patient would always look at his brother and then ask me, “Doc, what’s the next treatment option?” I knew we were running out of available options, yet his drive possessed me to try to find some treatment than could work.

Finally, after one visit, his brother came up to me and said, “Doc, you need to ask him without me in the room. He is making his decisions based on not letting me down. His heart has to decide what is best for him.”

I knew he was right. I entered the patient’s room without his brother and closed the door. As we talked, I was honest about the obstacles stacked up against us and, for the first time, explained that there is no cure, and the only option left was a clinical trial. I took my time and waited for him to respond. He was emotional and explained that he knew in his heart two treatments ago he was ready to stop and focus on comfort; he just couldn’t imagine letting his younger brother down. I explained that he should be honest with his brother and they should talk. He agreed. They talked alone, and 20 minutes later the patient decided to pursue hospice and focus on comfort and quality of life.

I have evolved quite a bit from fellow to attending. I have tried not to let my own optimism and fear of giving bad news hinder my patient’s best interest. When patients are diagnosed with a terminal cancer, they need to be aware of the realistic goals of treatment. Explaining the differences between curative and palliative treatments upfront is key. Just because a treatment option is available does not always mean it is the right treatment for the patient in your room. This is a constant struggle for me, and I try my best to stay true to my patients and respect their wishes when it comes to treatment.

Six weeks after my patient decided to stop active treatment, his brother sent me a card. In it, he thanked me for giving him more time to spend with his brother, and informed me that he died peacefully at home, surrounded by friends and family. He ended the letter saying he missed his brother every day, yet found solace in knowing he decided his own fate and found peace and harmony on his own terms, just as he had always done in his life. It is a lesson in heroism that I will never forget.

Originally published on Cancer Doc in Evolution; reprinted with permission.

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