Saying goodbye to a patient who's your friend

Sometimes, I think that many folks see oncology as an acute care specialty: patients get cancer, get sick, and then they die. There’s an impression that we meet patients only for a moment in time before they are gone forever. But speak to any oncology specialist, and you will see nothing is farther from the truth. While there are those whom we do indeed meet and know for only a short time, there are many others who continue under our care for months and years. Whether in remission or alive with disease, we even have those patients who remain in our clinics for decades.

For me, those long established relationships are often the hardest as well. After so many months go by, and we live through remissions and recurrences, we get to know patients as people — celebrating the birthdays of their children or the birth of a grandchild, grieving the loss of their spouse or siblings. We are there for major events beyond those related to cancer. These patients become part of our clinic and, dare I say, our lives, and it is the merging of patient-person-friend where, emotionally, being an oncologist can become quite complicated.

Such is the case with Nancy*. She and I met in my first year as an attending. She had ovarian cancer and had seen me for primary treatment. We hit it off right away — I was the same age as her daughter, and her granddaughter was the same age as my firstborn. She would come to clinic elegantly dressed, makeup applied — almost regal. She always smiled at me when I came in to the room, and despite fatigue that occurred as her treatments went forward, she always found a reason to celebrate; there was nothing that diminished her spirit.

She completed that initial therapy, and I saw her every 3 months for close to 3 years, before her cancer relapsed. From that point forward, it was a process of treatment to remission, surveillance, and then recurrence.

Except now, it was different. We found ourselves running through several treatments, and each time, her tumor marker would double after the first round. Then she developed pain in her right upper abdomen and scans had confirmed metastatic disease in her liver. Despite each trial of a new regimen, her metastatic disease continued to grow.

After her latest chemotherapy had not worked, she came to my office to discuss next steps. In her eyes, I saw a woman sad that her disease had not responded and tearful because of the stress her condition had placed on her family. After I examined her, we sat down. I started to talk, but she stopped me.

“Dr. Dizon, I trust you completely. If you tell me there’s another option, then I’ll do it. You’ve always done what you thought was best for me, and I appreciated it then, and I appreciate it now. So, tell me, what should I do?”

I was unsure how best to answer her initially. We had known each other for so long. Then I decided that my truth was the best response I could give. “As your friend, I want you to try one more treatment. I want you to live, and quite frankly, I am not ready to say goodbye to you. But, I need to guide you as your doctor, and even though it’s so terribly painful to say this to you of all people, in my medical opinion, the time has come to stop treatment.”

She closed her eyes then. When she opened them and looked at me, she smiled. “I know. I know it’s time — I can feel it in my body, that it’s tired, and I’m tired. In my own heart, I know it’s time too.”

I allowed myself to feel the moment, and together we cried. After a moment we talked about hospice and end-of-life care. She had me speak with her son and together, we decided it was best if he came back home. As she left my office, she smiled at me, and I smiled back.

“I will never forget your kindness, Dr. Dizon. Thank you,” she said.

Holding back my own tears, I looked at her one last time and said, “Nor will I forget yours.”

* Name and identifying details changed for patient privacy.