A cancer patient’s last wish [PODCAST]

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“I smiled, put the lamb curry in front of her, and instructed her granddaughter on how much time to heat it up in the microwave.

Val wasn’t in a condition where she could have a long conversation with me, but she knew exactly what was going on. I saw her eyes smile for a moment, tearing through the pain otherwise displayed all over her face. She didn’t say much, but just enough when she said, “God bless you.”

I left her house wondering when somebody is given the death sentence, they are asked about their last wish. We seldom do that in medicine. Should we?”

Farhan S. Imran is a hematology-oncology physician who blogs at Did I Ask?

He shares his story and discusses his KevinMD article, “A cancer patient’s last wish.”

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Transcript

Kevin Pho: Welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at kevinmd.com/rate. Subscribe at kevinmd.com/podcast. Today on the show we welcome back Farhan Imran. He’s a hematology-oncology physician, and his website is titled didiask.blog. His latest KevinMD article, which we’ll talk about today, is titled “A cancer patient’s last wish.” Farhan, welcome back to the show.

Farhan S. Imran: Thank you, Kevin. Always good to be back.

Kevin Pho: Now, for those interested in hearing more about Farhan’s story, just go to kevinmd.com/podcast. In the upper right there’s a search bar. Search for his name, and you’ll hear more about his story. But now let’s go straight into his KevinMD article, titled “A cancer patient’s last wish.” So Farhan, tell us about that story.

Farhan S. Imran: Sure. So again, thanks, Kevin, for the opportunity. I’ve written a number of times on your blog, and some of those are opinion pieces, but this is purely a patient story. In medicine, and especially in oncology, every patient brings their own story, but some stories are just so outstanding that it’s nice to put pen to paper. And just for everybody to know, this is totally HIPAA compliant. There are no patient identifiers in this story.

So basically, this was a day when I walked in. In oncology nowadays, we can do a lot for patients, especially if they have early-stage cancer, and even if somebody has stage four or metastatic cancer, where the cancer is incurable, there’s a lot that we can do. But this particular patient came, and I reviewed her chart before going in. She had stage four pancreatic cancer, which was very widespread, and she had so many other comorbidities that it was becoming very hard to offer her any treatments.

So I walked into the room, and I see this 60-something-year-old, very nice African American lady. Just looking at her, she had all the wrinkles and those years of self-abuse. You can start telling if somebody is a smoker or a heavy drinker; you can tell from their face, in a way, that they may have abused their body all their life. She was accompanied by her two granddaughters, who were very loving towards her, and they had a very good friendship going on. She was in a wheelchair, she had oxygen on, and she could barely walk. The cancer had rendered her so frail, so cachectic, that she probably weighed less than 100 pounds.

So I walked in, and her eyes were filled with hope, of course, as when you’re seeing your oncologist for the first time. I sat with her, I spoke with her, and towards the end I told her, “I am sorry to say, but I don’t think I have any treatment to offer you. I think that you should sign up for hospice, and you should go home on hospice.” All of a sudden I saw all the hope vanish from her eyes. But she still asked me a confirmatory question. She said, “Doc, are you saying that I should go home and die now?” That’s a tough question to answer, but you have to be very direct in your answer. So I said, “Yes, in a way, that is true. But if you were my mother or my aunt, I would have said the same,” just trying to validate that.

Kevin Pho: Let me ask about that, because of that question she asked you, “Do you want me to go home and die?” And you’re a very experienced oncologist, and you’ve dealt with that question many times before. How long did it take you to come up with a response to that question? Because if someone asked me that question, I wouldn’t know what to say in the exam room. So tell me the formulation of how you come up with a response to a question like that.

Farhan S. Imran: So first of all, it takes years, like you said, to come up with a response, and it comes from trial and error, because the answer to that is not in the books. It’s not in your physiology, psychiatry, or ethics book, so you have to come up with the answer yourself. And if you look at the theme of my previous writing, the science of medicine has advanced, but the art is lacking; it is going behind. So everybody comes up with the answer on their own.

So one of the things that goes through my mind is, number one, leave no doubt. You cannot be wishy-washy about your answer and say, “No, yes, this.” You have to look them in the eye, and at this time I definitely look the patient in the eye, and then I tell them that yes, that is the truth. But then at the same time, while you’re appearing very firm and very clear, you instantly have to give them a moment of hope and allay their fears. Because anybody who encounters somebody telling them, “You’re going home to die,” is worried about how they’re going to die, the act of dying, whether they’re going to be in pain, and all that. Basically, you’re reaching out to them and telling them that there’s so much that we will still be able to do.

Sometimes there’s some body language that some physicians use. I personally am not very good at using that. I personally grew up in a very insensitive kind of household, all five brothers, not very touchy-feely. But this is something where, if you truly think of that person as your own family member, then the true emotion comes out. So that is exactly how I addressed this kind of situation.

So up until now, whatever was happening in the room was a very routine occurrence for me. All of a sudden, she put her head back and started reminiscing, and teardrops came to her eyes, and her granddaughters also started crying. And all of a sudden she says, “Hey, Doc, you remind me of my boyfriend that I used to have when I used to live in New York City.” And all of a sudden I’m like, “OK, how do I respond to that?” To me, it was her attempt at showing her granddaughters that she’s strong and the news of death does not shake her, and in some way to change the topic or keep up with her jovial kind of nature.

So I just said, “OK.” And then she said, “He was from Pakistan.” And I said, “I’m also from Pakistan. That’s why I remind you of him.” And she said, “He was the best man I ever had, but then he left me. But I never had a man like that ever in my life.” So I honestly didn’t know what to say, and I was just listening. And then she said, “He used to make the best lamb curry ever.” And then I told her, “Listen, I make excellent lamb curry.” In fact, when my friends and I get together, I must have made it for them like 50 or 100 times.

So she turns around, and she says, “Would you fulfill a dying person’s last wish?” And I said, “OK, what is that?” And she says, “Would you make lamb curry for me?” Again, I didn’t know what to say. And then her granddaughters all of a sudden started saying, “Grandma, this is not what we’re here for. You don’t talk to the doctor about these things.” And this wasn’t my time to tell them, “No, this is exactly the conversation that I would want to have.” And I told her, “Listen, I don’t know, I don’t know, but you certainly got me thinking.”

So anyway, she left, and I didn’t even think I would do that. But then the weekend came, and I just could not get those words out of my mind. I’m like, “She said it. Even if it was joking, how would you feel the rest of your life if you did not fulfill a dying person’s wish? Isn’t that what you’re supposed to do?” So then I actually went, I bought some lamb, and I got cooking. And while I was cooking, I’m like, “OK, she has pancreatic cancer. I’m giving her antiemetics; she may be nauseous. She’s cachectic. How much spice to put in? How much to tenderize the meat?” and all that.

So finally I made it, and then I went to her house. I looked up her address in our Care Connect, the EMR. It was not the best part of town. I walked into a very small, one-room house. She was sitting on the couch, and it was also a firsthand experience of seeing a patient on hospice. She had at least two dozen empty beer cans in front of her on the table. There were cigarette butts in all of them, a thick cloud of marijuana smoke, and one of her granddaughters and her boyfriend were sitting there. I walked in, I talked, and I told the granddaughter how much to warm it up for in the microwave.

Kevin Pho: So even before that, when you just knocked on the door and they opened it and saw you, tell me about that moment.

Farhan S. Imran: So I was also nervous: “OK, what am I doing? How are they going to take it? What are they going to think?” So when the door opened, one of the granddaughters was there. She saw me, and she looked at me like she was not understanding, and she said, “Are you the doctor we saw the other day?” And I said, “Yes.” She couldn’t say anything, and then I said, “I brought some lamb curry for her.” She didn’t say much, and she led me. She said, “OK, let me bring you right to her.”

And then when I gave it to her, she was already a little bit disoriented, maybe from the narcotics that she was on, or maybe from the alcohol or marijuana, whichever. She had the oxygen on, and then she looked at me. She did not say much; she didn’t even have enough energy to speak that much. I didn’t stay too long. I did not have it in me to actually sit down, although now I think I should have. And I said, “OK, you really didn’t think that I would not fulfill your wish.” And then I was also thinking that maybe she would say something. The only thing she said in the end was, “God bless you.” And I think that was enough. Then within a day or two, the news of her passing also came.

So I had this feeling that, OK, if I could not help her in that way, at least. And this is not that I was helping her. This was just a human connection, a purely human connection. So that’s the story I put together in the blog.

Kevin Pho: Tell me the impact you think that made on that patient and the patient’s family.

Farhan S. Imran: I feel like a lot of people have a mistrust of the medical community. Probably not so much in America, but in Pakistan, where I was born and raised, everybody’s second-guessing physicians and their intentions. And even over here, especially in the African American population, with all the history of the Tuskegee trial and all that, and then the vaccines rolled out, they don’t trust physicians for one reason or another. And it’s very natural for that to happen. I don’t know if it happened or not, but I feel that even if one person thought, “OK, these physicians are out there not only for some agenda of their own, but they want to help you as a human,” if anybody thought that even for a moment, I would feel like I got what I wanted from it. That’s what I would say.

Kevin Pho: And in your long career as an oncologist, has this story, this moment, ever happened to you before?

Farhan S. Imran: So something like this has not happened. It was the first time for me, and that’s why it got me thinking. Typically in our palliative care rotations we talk about it, but I had not witnessed it. We talk about when a patient has a few days or a few weeks left, and we do this in oncology quite a bit. We sit down with the patient and we say, “OK, what else do you want to do?” Some people say, “I want to see my daughter graduate,” or “I want to see my grandson born, and I want to live for that.” So we often do that, but a lot of times we just leave it at that, and that’s the end of it. But this was the first time I got personally involved, and I felt, if I could be a part of a patient’s last wish, wouldn’t that be nice? And that’s an attempt that I try to make more of.

In the olden days, the doctor would actually visit the house, so the doctor would become a part of the household experience. They would bring you something to eat or drink, and you would meet with their kids and all that. Nowadays it’s very rare. I think in Rochester there are probably one or two physicians who make house calls anymore, but that has disappeared. So we don’t have to make house calls, but who stops us from going and visiting a patient’s house, or inviting someone to your own house? And then we all start making our excuses: “OK, if you ask one, then everybody’s going to be coming in,” or it just becomes an expectation. That’s all in our minds. You don’t have to do that with everyone, but wherever you make that connection, what is stopping us? Some of us go to funerals and wakes, but why wait for that? Why not do that even before, and just go and have these personal and human connections? That is how I look at it.

Kevin Pho: One thing in your story that struck me was when you walked into her house, and you were a little bit taken aback at the conditions in her house. So comment on that, because as you know, we don’t see patients in their home; we see patients in the exam room. I hear a lot of stories, especially during these televisits, that it’s really the first glimpse that a lot of physicians have of the background of what their living situation is. Comment on that.

Farhan S. Imran: That’s a great thought, Kevin. So if you look in the hospital, at all the inpatients, everybody’s given a gown, and when you walk in, any patient in a gown, they’re all just a patient. But there’s that famous saying that if you treat a disease, sometimes you win and sometimes you lose, but if you treat a patient, you will always win. That means that you need to get to know the person that they are. So if you take the same inpatient and tell them, “OK, instead of your gown, why don’t you wear your clothes,” and that’s OK, just by seeing their clothes we learn so much about them. Somebody’s wearing a Harley-Davidson T-shirt; now, he’s a biker. Somebody’s wearing a hiking T-shirt; you get to know them. Then on top of that, if you actually go in and see their living situation, who else lives with them and all that, that just gives so much of a different perspective. And believe me, at least in oncology, you start making different decisions for them.

So for example, I had a patient with whom I was talking about three different treatment options, and she was not being engaged in that discussion. So I put that discussion aside for a second, and I said, “OK, what’s on your mind? What’s going on?” And she said, “Doc, at this time all I’m worried about is that my cat is sick, and I’ve put all my money towards that. And on the weekend my fridge broke, and I don’t have the money to fix my fridge.” So right now, should I be sitting there and talking to her about the three different treatments and the overall survival and progression-free survival? Or should I say, “Let’s dismiss this conversation until we get your fridge fixed,” and all that, and then we go from there?

But the way we handle that situation is, “OK, I have 15 minutes. I have to move forward. Just quickly put the scan orders in. Get social work. Get social work.” The minute anything personal comes up, a physician’s natural, instant response is, “Oh, I’m going to have social work get together.” And then social work comes and arranges some transportation and all that. I feel like that’s not a good way of doing that. So that’s why visiting a patient and knowing their personal situation, their household situation, is just so much more important than reading their prognosis curves on UpToDate. That’s how I feel.

Kevin Pho: Farhan, my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Farhan S. Imran: Well, for this one, I would just say get to know your patients. And I’m doing something very much fun. We have medical students, residents, and fellows. Teaching is a big joy at our institution, as it is at many other major academic institutions. So what I’ve started doing is, with my medical students or the interns on the team, if I’m doing one week of inpatient with them, I tell them that during this one week, you have to find out one personal thing about each patient that you see, something that has not yet been documented in the EMR, and that should be your personal connection. So basically, just find a hobby together, something personal together, and then tell me.

And then I also tell my students that next time you’re discussing a case in morning report, instead of how we have traditionally been taught to start the presentation with the chief complaint and the history of present illness, start with the social history, and just go on and go deep. Just don’t say, “This is a city firefighter.” Just say, “Hey, he’s a firefighter, and he was involved in that fire, and he has a scar from there. He has three dogs at home,” and blah, blah, blah. That way, not only do you demand the attention of everybody in the room, but the story becomes nicer. It tells you that you know the patient, and it just makes it more interesting. And that way you are not treating just some diagnosis; you’re actually treating patients. So one take-home message for this one is get to know your patient very closely.

Kevin Pho: All right. Farhan, thank you so much for sharing your story, time, and insight, and thanks again for being on the show.

Farhan S. Imran: Thank you, Kevin.

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