She had been admitted overnight: a previously healthy 62-year-old woman who had been blindsided by acute onset of abdominal bloating and pain 6 months prior. A flurry of tests showed she had pancreatic cancer, and that it was advanced. She had started chemotherapy, but the regimen was so toxic; she suffered from unrelenting nausea and fatigue to the point that in the last 6 weeks she had gone from playing tennis every weekend to becoming unable to rise from bed. In the last 24 hours her family witnessed a significant decline. She was awake only sometimes, and when she was, she was incoherent. This prompted her admission.
I was on service then, and even though much time has passed, I still can see her face. With IV fluids and the correction of some lab abnormalities, she had “woken up”—able to speak to her family and clearly aware that she was in the hospital. I saw her the next morning and asked how she was doing.
“Well, I could be better!” she stated. She told me about how the pain had gotten worse recently, that chemotherapy was making her feel worse than before, instead of better. “I had no idea it would be this hard.” We had also done a CT scan, which showed the worst: the cancer was now in her liver, where multiple sites of metastases had grown despite chemotherapy.
Because I am not an expert in upper gastrointestinal cancers, I reached out to her primary oncologist. As we spoke, there was sadness in his voice that his hopes for her were not being realized. He had hoped to alleviate her suffering with chemotherapy but had been frank with her that the cancer was too advanced for surgery and that our treatments would not induce a remission, just—hopefully—give her more time. Unfortunately, he was also away at an international meeting and would not be back for the rest of the week. I told him about the CT scan, asked him his opinion.
“I think her options are really limited, especially since she feels so poorly. I think she needs to know she’s dying,” he said.
At that point I felt a discomfort—because it was my turn to be the inpatient rounder, somehow it would fall on me to deliver this news. As we talked I thought about asking him who would tell her. Surely, there was someone covering his outpatient practice. Surely, there was someone in his group who could break this news. Couldn’t his nurse practitioner do it?
But then I thought about her. That she needed to know the results of her scan and what it meant. That she deserved to meet with someone sooner rather than later. That absent her primary oncologist, she deserved to meet with someone who had the time to sit with her and her family.
Oncology has evolved so much, with better treatments and better supportive care options, that much of what we do, we do in the outpatient setting. Our clinics tend to be filled with patients, making the task of caring for those in the hospital so much harder. At MGH we have sought to meet the needs of our patients both in and out of the hospital as many other institutions have done: by assigning an attending as rounder. It becomes the rounder’s responsibility to oversee the care of patients, to have meetings when needed, and to establish plans for acute levels of care. Most times, a patient’s outpatient attending can be called upon to meet with the patient and their loved ones, especially if one is at a critical point in their own cancer journey. But, as is often the case in a busy academic practice, sometimes it’s just not possible. And this was one of those cases.
So to my colleague, I simply said, “I will take care of it, if it’s okay with you.” He thanked me for this, and then hung up.
With that, I made arrangements to meet with her and her family, alongside her entire team of palliative care clinicians, nurse, nurse practitioner, and social worker. Together, we told her what we knew and what she needed to know—that her cancer had progressed, that treatment was not working, and that we feared she was dying. She had expected as much, especially since she had seen herself declining so rapidly. We decided together to stop chemotherapy and transition to end-of-life care, with a focus on comfort measures and symptom control.
In a system of inpatient rounders and busy outpatient clinics, sometimes patient-centered care can be difficult to aspire to. But holding on to our own humanity, maintaining empathy, and remembering that each patient has a name, a family, and their own story helps to remind me just how important the task is. So, as rounder, I have learned to treat each inpatient as my own—even if it is only for 2 weeks.
Our patients expect this of all of us, and I have learned that my colleagues and I expect it of each other.