Spring 2004
The author is a 2003 graduate of Johns Hopkins University School of Medicine. She is currently completing a residency in internal medicine at Johns Hopkins Bayview Medical Center. This paper was a submission to the 2003 Alpha Omega Alpha Helen H. Glaser Student Essay competition. The first time I saw “The Doctor” was about three years ago during one of our weekly Physician and Society classes in medical school. The lecturer commented that being a physician is not just about treating patients, and that sometimes all we need to do is to be with the patient, as in this painting. I did not quite comprehend the emotion in this painting until three years later, when I met Miss D and her family. Miss D came to our service on a Friday afternoon in the middle of August 2002, when I was doing my oncology elective at Johns Hopkins Hospital. We learned that she was a 23-year-old woman with newly diagnosed familial adenomatous polyposis (FAP) and metastatic carcinoid tumor. Instantly, there was a sense of excitement in our team. After all, it was very uncommon for us to have so young a patient coming in with such a severe condition. I knew that with the modern technology and medical therapies at our disposal, we would be able to help her. We rounded on Miss D first the next morning because she was the sickest patient on our service. The intern who had admitted her the night before told us that she had been healthy except for a long history of chronic diarrhea before she was admitted to the hospital for nausea and vomiting three weeks ago. She underwent colonoscopy, which showed thousands of polyps in her colon, and she was diagnosed with FAP. Her abdominal CT scan showed a large liver filling up at least two-thirds of her abdominal cavity. The liver biopsy was consistent with metastatic carcinoid tumor. She deteriorated quickly. The day of her transfer to Hopkins, she was already severely jaundiced and confused from acute liver failure and hepatic encephalopathy. Her prognosis was poor. When we entered the room, she was lying in bed, jaundiced and obtunded, her head tilted backwards on the pillow, eyes closed. Her mouth was wide open and her breathing was regular, deep, and fast. We spoke to her, but she didn’t respond; she only mooed weakly when we squeezed her arm. If not for her smooth and young looking skin, I would have thought that it was a dying elderly woman in that bed. Discouraged, we left the room. No one said anything at first. Carcinoid tumor is a rare GI neuroendocrine tumor, and although it is less aggressive than the more common GI adenocarcinoma, it has very low response rate to chemotherapy. Surgery was not an option, and radiation is not recommended in treating GI cancers. Palliative care seemed to be the only thing we could do. The family meeting occurred soon after we finished rounding on our other patients. The oncology fellow on our team summarized Miss D’s situation. He told her parents that she was going to die and that there was nothing we could do to cure her. We could put her on ventilator in order to prolong her life, but most likely she would never awake. Miss D’s mother, sitting on the folding bed next to her daughter’s hospital bed, started to sob. Then her father, standing next to the hospital bed after refusing to sit down, suddenly knelt down, held Miss D’s feet and began to cry. Our attending, a mother of three grown-up children, quickly moved to sit with Miss D’s mother, put her hand on her back, and passed her a tissue. Our fellow stopped talking—he was trying to hold back the tears in his eyes. Our intern stood like stone, her hands clenched so tightly that I could see her whitened knuckles. Our nurse was sobbing, too. Tears began to run down my face. The whole room was filled with sadness. After a few minutes, Mr. D wiped his face, stood up, cleared his throat, and told us that he understood what was going to happen. He was ready to let his daughter go when her time came. They wanted DNR and DNI. Later, I realized that the time we spent grieving with the family had healing power in itself. They seemed to be at peace with their daughter’s coming death. During morning rounds, I rarely saw Miss D’s mother crying again. Instead, I usually saw her smiling while holding her daughter, and saying something encouraging or loving. Ten days later, Miss D died. I think about her often. I want to thank her for the minutes in her room that taught me that when there is no medical treatment I can give, I can still sit with a patient’s family, hold their hands, and cry with them. This is the meaning of Sir Luke Fildes’s painting. The author’s address is: 223 K East Northern Parkway |
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