By Ligeng Tian, MD, PhD
Virginia Oncology Associates
Helen* had received multiple lines of chemotherapy for a stage IV breast cancer. She had been off treatment for quite a few months now and declined hospice because she did not like strangers in the house. I met her when she was admitted to the hospital, this time for symptomatic ascites and severe anemia. The plan was to discharge her home after paracentesis and transfusion.
On my exam, her left leg was quite swollen, suspicious for DVT. I explained to her that a DVT could be dislodged and travel to the lung, and was potentially life threatening. If a DVT was found, she would need anticoagulation. However, if she decided not to pursue the DVT workup because of a desire to not be burdened about this treatment in her stage of life, I would understand why.
She decided to go for the Doppler ultrasound.
The ultrasound was positive, and a heparin drip was started due to renal insufficiency.
On day 3, Helen was found to be hypotensive, and her hemoglobin dropped by two points. She also complained of abdominal pain, and I thought, “Oh no, she could be bleeding into the abdomen!” Urgent transfusion was started, and a STAT CT was ordered. The CT showed a large hemorrhage into an intra uterus lesion, showing diffuse white color on the screen.
A vascular surgeon was called in to place an IVC filter, but the patient’s IVC was not visible; Gynecology was consulted for possible surgical intervention, but given the patient’s end-stage cancer, she was deemed a nonsurgical candidate.
I felt terrible, but I had to go in and break the news. I held Helen’s hands, and said, "I am so sorry about what has happened. We really should not have done all this. You have undergone so much torture for nothing, and now we are back to square one, even worse!"
To my surprise, Helen was not upset at all. She held my hands back, and looked into my eyes, saying, "I know I am dying, and I am ready for it. I do not want to do anything anymore. Let me go home, please."
I have to say I felt relieved, yet guilty.
Helen went on: “You know, you are beautiful, inside out, because you care. Trust me, I have lived 73 years and have seen a lot. You go on and take good care of all your patients. I am ready for my lord, and I am ok with that. "
She was not the first, or the last, patient who had put his or her full trust in my hands, letting me do what I feel is right.
My patients and I have walked together along the long axis of time, with no turning back. The decisions I have made at any given time could only be proven right or wrong by time. The question is always: Should we fight for this, and the patient may live longer? Or shall we seek comfort care, because the patient might suffer in vain?
I do not have an answer.
All the decisions I have made were the best I could make at that moment for that specific patient, all the while, with a philanthropic heart and an oncologist's mind.
As long as we do not regret.
*Name and descriptors changed to protect patient identity.
Dr. Tian is a Medical Oncologist and Hematologist at Virginia Oncology Associates in Hampton.