I met Marie as a gentle and kind-hearted woman in her early 50s. She and her husband lived with their adult children and grandchildren on a farm in rural NSW. A couple of years earlier she had been diagnosed with melanoma after she noticed a lesion on her shoulder. The melanoma and regional lymph nodes had been removed prior to adjuvant chemotherapy. Recently however, Marie had developed pain in her hip. Her medical oncologist arranged an x-ray which revealed what was likely to be a metastatic deposit in her neck of femur, indicating not only that there was evidence of distant metastases, but also that her hip was about to break unless the bone could be stabilised. She was quickly transferred to Sydney under the care of her medical oncologist for urgent surgery to prevent the fracture.
As her treating team, we anticipated a short admission of a few days before returning Marie back home where she could receive ongoing treatment at her local base hospital. Unfortunately however, Marie’s admission soon became one of the most medically complex and emotionally exhausting I have been involved in. Shortly after Marie arrived in Sydney, my consultant and registrar were due to leave for a conference, leaving me as the familiar face that Marie and her family would turn to whenever they had questions, suggestions or required emotional support.
Pulmonary emboli delayed the surgery. Marie then developed a new cough and was subsequently found to have hospital-acquired pneumonia. We investigated aspiration as a possible cause for the pneumonia, to discover that Marie’s swallow and cough reflex were impaired. A CT of her brain revealed numerous cerebral metastases and destructive bony lesions of the skull. I was floored. I couldn’t believe that this beautiful person who had presented to us for a straightforward operation would now learn that her cancer had spread to the brain.
Whilst her family were devastated with the news, Marie remained stoic. Together we reassessed our treatment goals. Although it was impossible to predict how much longer Marie would live, this new finding indicated an aggressive and advanced cancer with limited treatment options. Marie voiced a single request: to return home for Christmas. In discussion with Marie and her family, we abandoned the surgery, and instead focused on keeping her alive and symptom free for as long as possible.
Each morning that I arrived at work, I dreaded what the day would bring. As Marie’s hip pain worsened, she was no longer able to walk. But she also developed pain in other areas of the body. Her family noticed new subcutaneous nodules on her back – metastases were appearing before our very eyes. To prevent the risk of choking, Marie’s diet was limited to pureed food and ‘thickened water’ – a substance that closely resembles saliva.
As Marie’s admission prolonged, her family and friends travelled to Sydney to visit her. I was covering the ward on a Sunday in early December when her two daughters came to visit. Unsurprisingly they had lots of questions about their mother’s medical care. Whilst the situation was undoubtedly an unfortunate one, I tried the best I could to reassure them that we were doing everything within our ability to make Marie as comfortable as possible. Although we all wished for Marie to be able to return home, we would have to wait for her usual medical oncologist to return the following day to review the situation.
Later that afternoon I passed Marie’s daughters in the stairwell. Their eyes were red from the tears they had been crying, and their faces exhausted from sleepless nights of worry. They stopped me to thank me for everything I was doing to help their mother. And what they said next struck me like a thunderbolt – ‘Mum told us not to worry about her. She said “Don’t worry about me. Everything is going to be alright because Duncan is taking care of me”’.
After putting on a brave face for so long, it was that one remark that broke me. But I couldn’t let it show. I held myself together for just long enough to say what a privilege it was to be able to work with Marie and her family before I bolted to the nearest doctors’ room, blinking away the tears in my eyes. As soon as I closed the door behind me, I burst into tears. What I felt was a mix of emotions. Having spent much of my internship feeling like a glorified clerk, I was humbled to be recognised as an important and valuable person in Marie’s care. But at the same time I felt completely helpless. Despite everything we were doing for Marie, she was dying and there was nothing we could do to stop that. I felt guilty that we couldn’t offer her a cure and make this nightmare go away.
The following day, Marie’s medical oncologist returned to work. I was relieved that there was finally someone else who she knew and trusted, who could help to relieve me from my emotional burden. After he spoke with Marie and her family, it was decided that Marie was too unwell to return home, and that if we attempted to transfer her back, there would be a risk of her dying in transit.
Marie died just two weeks shy of Christmas and 300 km from home. But if home is where the heart is, it had been recreated at her hospital bedside. Each time I went to check in on her, she would introduce me to family and friends who had come to cherish their last moments with her and say their goodbyes. Marie had said that she ultimately wanted to be surrounded by loved ones, and these were something of which she had plenty.
Although we ran out of medical options to prolong Marie’s life, I was privileged to be able to work with her during her final days, and it was through this experience that I realised that the healing power of medicine extends beyond pharmacotherapy. As a junior doctor, it is easy to feel as if you fly under the radar and go unnoticed. But I have learnt that the work I do is not only important, but also highly valued by patients and their families. To Marie and her family, I was not just a junior doctor. I was a human being who was there to listen to their concerns, answer their questions, recognise and share their pain, and support them to the best of my ability.
All names, personal information and clinical presentations have been changed in the interest of protecting patient’s privacy.
Originally published: Sunday 27 November 2015