Case 3 A 70Year Old Man with Widespread Cancer

On his return from a well-known medical center where this patient had been receiving chemotherapy for widespread cancer, the retired executive's wife called to ask that I become his physician. The initial treatment had failed, an experimental drug was being offered with "less than 25 percent chance of success," and he was having ongoing pain that medicine poorly controlled. Stopping chemotherapy had not been considered. The adult children lived at least three hours away by plane. Prior to this call, he had no primary physician in his hometown.

On my first visit to his home, we concentrated on pain control, and I prescribed ibuprofen, a mild but often effective drug when given regularly several times a day. Subsequent visits concentrated on achieving better pain control using morphine, on helping him understand his illness (he knew that the prognosis was poor), and on addressing alternative ways of treating the progressive malignancy, including more chemotherapy. He declined the latter.

With his wife, we also talked about their experience and their fears. "What's this been like for you?" I asked. It was clear that they had a strong, mutually supportive relationship and that they were sharing the story of the drama of his illness with their out-of-town children, who began to appear at their home for prolonged stays. As time went on, a hospice nurse became involved, and she and I collaborated with the family on his care. Even though his condition continued to decline, the family was becoming more and more self-sufficient in meeting his needs and their own. With their concurrence, my visits became more widely spaced; they did not need me as much. He died within a few months of my first visit.

Here is what I learned:

Once more, medicine is a collaborative effort, and the most important participants in the collaboration are the patient and family. Consulting physicians, social workers, nurses, and clergy help. Their different points of view may reflect their professional paradigms of care, who they are as individuals, and their values and prejudices, which they may not even recognize. But there must always be a primary caregiver, the general contractor who is ultimately responsible and who can integrate diverse points of view into a single set of recommendations and a plan. Someone has to be in charge. Though I provided no specific anticancer treatment, I did much more. I assessed his needs and the needs of his family in the broadest sense, and I addressed his prognosis with all of them. I involved others—family and hospice nurse—in his care.

Illness is not a single moment but a dynamic process in which people can come to terms, make peace, and learn how to cope. The physician's role needs to be dynamic to accommodate these changes. Though I was more important to the patient and his family in the beginning, as the family rallied, became more active in his care and in looking after each other, and as other professionals became involved, the need for a physician lessened. To have continued frequent visits might have been seen as an intrusion.

0 0

Post a comment