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I have a book to keep track of all my patients who have died. It varies from one to 10 people a month, and looking through it is a humbling reminder of courage, faith, and the value of families and their support. I also have less inspiring moments of fear that in these times of quality measurement, Medicare will publish a list of doctors who have cared for some threshold number of patients who have died, it will be front-page news, and I (and my oncologist peers) will be at the top of the list. We all know that being an oncologist means getting to know many people who succumb to their malignancies.
In these difficult circumstances, we try to do right by our patients, walking the line between pessimism and hope. We aspire to guide our patients to a realistic acceptance of a terrible circumstance. Although we respect our patients' decision making autonomy, we recognize that they have come to us for expert advice. We are not the only professionals involved in these discussions and decisions. I asked my favorite hospital chaplain how she frames the end-of-life discussion, and she winked as she said, “Oh, I just say if Jesus wants you, do you want to put up a fight?”
We know that hospice care, for adults at least, often means foregoing antineoplastic treatments and even transfusions. One Christmas day, I visited a patient with widespread bone metastases of breast cancer and marrow failure who had recently lost her vision because of occipital metastases. She had GI bleeding and was receiving platelets and red cells daily. Hospital staff were reminded every day that the usual holiday blood shortage had arrived, and I asked her husband whether it was fair for her to receive so much of this scarce resource. It is still uncomfortable to remember his shock of anger (and my shock of understanding) as he said to me, “Is there someone else more deserving?” I asked her what brought meaning and pleasure to her days, and without hesitation, she said, “Some mornings I can feel the sunlight on my cheeks, and every day I talk to all my children.”
We all know patients who carry on with astounding courage. In the past few years, two were pleased to tell me that Tim McGraw's version of “Live Like You Were Dying” captured their experience well. Two others have even managed to write me thank-you notes to be delivered by their spouses after their deaths. One man and one woman—one my peer in terms of culture and situation, and one not—were not lucky enough to end their lives in a Hollywood-style, alert, painless, sanitized death. Both had significant pain, and both were troubled by the problems of sacrificing mental alertness for relief. Both had faced their incurable circumstance for months with something less than acquiescence that still approached acceptance. And yet in these circumstances, both had taken their limited time and energy to thank me—and both had asked me to convey their thanks to my clinical nurse specialist and staff as well for the efforts we had made.
Those who help others are often frustrated that they cannot do better, particularly in the challenging field of oncology. But we also have an amazing opportunity to be reminded of the fragility of life, duties of trust, and importance of those who work with us toward the same goal. Although the situation is clearly less pressing—and to the best of my knowledge neither I nor those I would like to recognize are going anywhere—I would be remiss if in this, my last column as chair of the ASCO Clinical Practice Committee, I neglected to acknowledge those many people who have worked with me during the past year, including Drs Penley, Hayes, Mulvey, Langdon, Lichter, Bailes, and Blayney and all the Clinical Practice Committee members. And with frank acknowledgment that it is more difficult to execute the details than to conceptualize them, I must thank all the ASCO staff who are particularly adept at making all this happen. So thank you, too (with sincere apologies to those not included in this truncated list), Drs Hagerty and Kamin and Mss Cathro, Hamlin, Nixon, Perkins, Tompkins, Towle, and Sastry. As one of those other thank-you notes might have said, although the time passed quickly, and although clearly I did not accomplish as much as I had intended, it has been wonderful working with such wonderful people.