By Joshua Davis

Resident Physician, Internal Medicine

Beth Israel Deaconess Medical Center | Harvard Medical School

Coping differences

The other day at work, I had the fortune to meet a lovely patient, Ms. H. She is a selfless, self-described runaway, who knew she had cancer. She had run away from home at a young age. She works now as a child therapist, but volunteers in a myriad of ways: teaching self-defense martial arts classes, a big sister to other similar runaways and teen moms. Her degree of selflessness inspires me – we need more people like her in our world – so my job is to keep people like her alive as long as possible, paying it forward to the rest of the world.

She had just found out that her cancer was metastatic. Hearing about how interesting of a person she is, I hurried over to go see her. As I got up to go see her, my resident advised me “she’s having a hard time coping.” That got me thinking, who and what is to determine how someone should cope?

I wondered what she meant by that – was I going to go in the room and she’d be uncontrollably sobbing? Did she warn me so that I wouldn’t cry? Which also got me thinking about a doctor crying (see below). I had no idea what to expect when I walked in.

I apprehensively entered her room. A puffy-eyed and, fire-red-spiky-haired woman of mid-50s age or so was lying in bed breathing softly. Her nurse was every so delicately caring for her, by accessing her port. I introduced myself as her doctor, gently shook her hand and sat on the bed with her, holding her hand.

I opened with a simple, “how are you?” She welled up and said, “I’m trying to deal with this news;” she started crying and said “I’m sorry.” Is this what my resident meant when she said she’s not coping well, I thought to myself? And if so, why is this not coping well? She just found out her disease is metastatic. It’s hard to put yourself in other people’s shoes – but I imagined this is exactly how I would react if I found out this news. She wasn’t having a hard time coping; she was coping the way she coped. In fact, I would describe it as appropriate. If she weren’t upset, I would wonder why not? Maybe she doesn’t understand what’s happening.

We talked about her symptoms and how I could help take care of her. We spoke about how she wanted to break the news to her family. When her sadness became too much for her to handle and she broke down, we smiled about all the kids she helped, and laughed about their shenanigans.

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Going through such difficult times in life is difficult for anyone to do – even more difficult doing it alone. I asked her who she got her support and strength from. She told me about her 5 sisters, living all over the country, her close personal friends and the children she mentored into adulthood. No one patient or family is the same – and everyone derives their support from different places. At the end of the day, they should feel that their doctor and the rest of their medical team taking care of them is walking through this journey with them.

Code status

In wrapping up our initial discussion, my job responsibilities came to the front. The discussion of code status was my responsibility. There is nothing that makes an intern’s heart palpitate more than a code status discussion with a cancer patient, especially one that’s “not coping well.” I worried about how to gently broach this. I felt my heart begin to race, so I took a slow deep breath with her.

Code status is the shop talk for, do you want CPR or not? It’s a much more difficult and intense conversation than I’m boiling it down to, mostly because it involves us dealing with our own mortality. Ben Franklin once said that there are only two things in life that are certain, taxes and death. Doctors have a corollary joke, playing off the hard data and percentages we always reference from research papers. “The death rate is still 100%.” The discussion of code status hinges on how people want to imagine their mortality (or don’t want to, for that matter).

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I assured her, not because I was worried about this happening eminently, but because my goal is to provide care for her, and every patient, the way she/they want to be cared for. “If your heart stops, or you stop breathing,” I asked her, “would you want us to do everything we can, including compressions & electric shocks to try to bring you back?” – no tears, I sighed a mental sigh of relief. She vehemently said, “I don’t want a breathing tube.”

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With other patients, I’ve had a variety of other experiences. In another lovely woman, mid-40s, with advanced pancreatic cancer, when I asked her about her code status, she said that she hadn’t thought much of it. This surprised me. How could she not think about that, I asked myself? I didn’t press her on this, but said that this is something everyone should think about, regardless of advanced cancer or picture of health. And furthermore, that these wishes be communicated with a family member or their doctor.

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Final Thoughts: My Personal Reflections in Oncology

I had always thought that oncology would never be something for me – I couldn’t handle all the sadness, fright and death. After working 12+ hour days, six days a week this past month, I’ve had a complete change of heart. What scared me away originally from oncology, is now what drew me in. These patients and family members need someone to hold their hand and walk with them through the most terrifying time in their lives. This has been the most rewarding experience I’ve had and underlines why I went into medicine. Patients are much more than their disease. Getting to know who they are as people before their disease, while making it that much harder when having to deliver bad news, makes the job so much more rewarding.