A Clinician’s Perspective

“So how long do I have?” he asked. 

And there it was—the weighted question we clinicians are asked that can change the trajectory of a patient’s path.

I walked into the exam room, and my 43-year-old patient was on his phone. He was not quiet in his conversation—he threw out multiple curse words while he continued to talk. Entertained, I waited. He finally hung up.

“So, what’s the news, Doc? Just cut to the chase,” he said. He was leaning back in the chair with one ankle crossed over his opposite knee.

David had widespread colon cancer involving the lungs and liver. His cancer outgrew and outsmarted four lines of chemotherapy. He had chemoembolization twice to his liver lesions. The results of the molecular studies on his tumor specimen revealed no mutations or alterations we could target. At that time, he was on a last-ditch effort oral chemotherapy regimen. He had returned to review scans and lab work; the results were not good.

“Unfortunately, the scans show the cancer in your liver is worse, and you are accumulating fluid in your abdomen. There are also new spots in your lungs. Your labs show the tumor marker has tripled, and liver function tests are very abnormal,” I explained. Just in a snapshot exam across the room, I could see his abdomen protruding more since the last visit, the loss of weight from his typically burly arms and legs, and the yellowing of his skin.

Giving bad news never gets easier. Worse yet, after 23 years of experience in oncology, it often becomes apparent when the end is nearing for people before they have any idea. A clinician can get caught between hope and reality. They must understand what the patient needs to hear and decide how to deliver that information. In this case, David was a straightforward, tell-it-like-it-is guy.

“So, how long do I have?” he asked. And there it was—the weighted question we clinicians are asked that can change the trajectory of a patient’s path. I told him that we would also talk with the physician, but given our last option for treatment was not working and his liver was failing that, he probably had weeks to a month left to live.

He teared up that day. After four years with this patient, he finally cried. It ripped my heart out. This man was the owner of his own construction company. He had a 15-year-old daughter. He carried a chip on his shoulder, which sometimes rubbed people the wrong way. In fact, most of my co-workers preferred not to see this patient because he could be so abrasive. He refused to see certain providers. Somehow, I had stuck with him and could see past his rough exterior.

David was a deer hunter. At this visit, he told us he would go on a hunting trip with his friend that he had planned for months. Given his condition, the physician and I both had reservations, but we encouraged him to go and enjoy himself on the trip, knowing that it would likely be his last.

When David returned from the trip, he was jaundiced, and his lab work suggested that his liver and kidneys were failing. His abdomen was distended with fluid, causing him significant discomfort. He told us that he shot a deer. It had meant the world to him.

David’s friend, who came to most medical visits with him, hung back after David had completed his visit. He again asked the question, “How long does he have?” He said he needed to know because he wanted to bring him to his home to care for him in his final days. I told him it was time.

David died surrounded by family and friends. At 43, with a 15-year-old daughter, there is no plausible explanation for this tragedy. Cancer can happen to anyone. It is not selective. It is not fair.

David was a patient I will never forget. He could be impatient and formidable. He could be rude and crass. He could also be kind and vulnerable. As health care providers, we encounter many personalities and must develop the art of working with each. We may not like a particular personality, but we are responsible for learning to navigate it. David taught me something with every interaction we had. I am grateful and deeply honored to have known him.