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Can You Cure Him, for the Baby’s Sake?

From the University of Arkansas for Medical Sciences, Little Rock, AR, and The Johns Hopkins Oncology Center, Baltimore, MD.

Address reprint requests to John H. Fetting, MD, Johns Hopkins Oncology Center, 600 N Wolfe St, Baltimore, MD 21287; e-mail: jfetting{at}jhmi.edu or Paulette Mehta, MD, University of Arkansas for Medical Sciences, 4301 W Markham, Slot 503, Little Rock, AR 72205; e-mail: raylindaarlene{at}uams.edu.

Given up for good, he comes into my clinic,
See my young wife? he asks, pointing to a woman
30 years his junior, young but worn, adding,
We have a baby who’ll be born next year
If only. . . you could help us.
The cancer came in May, he says,
Many meds made him better
But now in relapse, released from care, hope all gone,
Couldn’t I do just a little better? If not for him,
At least then for the baby?
I realize there’s no hope, the cancer’s spread
Throughout his bones and marrow,
Liver, skin and
Lungs.
I ponder how could someone so weakened from within
Stand the stress of drugs,
And how could drugs so long ago used up
Offer any chance?
My mind says NO: not here, not now, not ever and listens
In astonishment as my heart responds so sweetly:
Yes, we have new treatments, if not for you
We’ll do it for the baby.
A course of chemo curses through his body,
Infection rages through his bones, sepsis saps his will,
Fungus settles in, all hopes are dashed,
His body now lies listless.
Later, as we sit and talk, me and his now-widow,
I say I’m sorry I couldn’t cure the cancer
Which took him from his baby.
We knew you couldn’t, she murmurs
It’s not his baby anyway,
We were desperate and we bargained you
For things we knew you could not do
For him,
For me,
Or any little baby.

Paulette Mehta
University of Arkansas for Medical Sciences
Little Rock, AR

DR MEHTA deserves to be congratulated for this poem. Whether the clinical story she describes in this poem actually happened as written, I do not know. It does not matter. The poem is emotionally real and true. In a few well-chosen words, Dr Mehta has vividly described the desperation of a patient and his wife. Similarly, she has vividly described the compassion, ambivalence, and vulnerability of a physician. The deception about the child dramatizes the desperation of the patient and his wife, as well as the vulnerability of the physician. In this poem, by getting to the heart of a desperate, end-of-life clinical situation, Dr Mehta has provided a unique perspective on one of the most important issues in medicine.

The dilemma faced by the physician in this poem is a dilemma all oncologists face. Confronted by a desperate patient, and treatments of limited value, should we treat, or should we not? This poem is not just about the dispassionate weighing of benefits and risks, however. It is about the emotional connection between a doctor and a desperate patient. This poem tells an essential truth about us as doctors. It tells about our readiness to have our heads turned and our hearts moved by the predicament of our patients, especially our desperate patients.

Most patients are able to face the limitations of treatment and the end of their lives without the searing desperation evinced by the patient in this poem. Some are not. They are determined to fight. They won’t believe that there is not something out there in which they can hope. The prospect of not continuing the fight fills them with an anguish they want to avoid. These are patients who challenge us saying, "Don’t give up on me." They feel abandoned if we recommend against additional treatment. They feel betrayed if we don’t share their hope for cure. If they have to die, they want to die on treatment. This poem speaks to how we are enlisted by these patients.

This poem also speaks to the personal, intimate, and idiosyncratic qualities of decision-making about stopping treatment for cancer. There is little in the way of science to guide us. The trials that apply to these situations don’t speak unambiguously about what to do. Many phase II trials of active agents or regimens in heavily pretreated patients have few responses. Some might interpret these trials as indicating that the regimen is not worth it; others may see the regimen as a ray of hope. There has not been a concerted effort to develop and promulgate guidelines on stopping treatment.

What about the bargain struck by the doctor and patient in this poem? Was it a good one? If one considers only the two principal parties in the bargain, the patient and the doctor, I think it was. The patient was informed about the potential benefits and risks of treatment; the doctor provided treatment that offered a ray of hope for survival until the birth of the child.

When we strike bargains to treat patients, however, we commit other resources: physician colleagues who cover for us, nurses and other staff, hospital beds, and so on. Not infrequently, colleagues, nurses, and other staff will think the bargain is one that commits them to providing futile care. Fighting and losing too many desperate battles has a depleting effect. There is also a cost that we pay as a society for the well-meaning decisions of doctors and desperate patients: resources we expend at the end of life for marginal benefit could be used to greater benefit elsewhere.

We need to find ways other than additional treatment to help these desperate patients. It will not be easy. We will need a concerted effort. If saying "no" to treatment is like a dagger in the heart of a desperate patient, it is hard for a doctor to say "no." It is also difficult to say "no" if another physician will say "yes." Specific guidelines about ending treatment would need to be developed. There would have to be buy-in by practicing oncologists. It will be easier to say "no" if we know that our colleagues will say "no." We will also need to do a much better job of preparing patients earlier in the course of treatment for the eventual day when there will be no more treatment. We should not have any illusions, however. Helping desperate patients come to grips with the end of their lives is hard, emotional work for all involved. The costs, though, are more justly borne.

John Fetting
Johns Hopkins Oncology Center
Baltimore, MD

AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The authors indicated no potential conflicts of interest.

Submitted March 17, 2003; accepted August 26, 2003.

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