My Condolences

“All I want is a way to clean myself after I make a mess.”

I began mentally reviewing my patient's CT findings: metastatic cervical cancer to the lungs, lumbar spine, and liver and left lower-extremity deep venous thrombosis. I spent most of the previous night poring over the literature: How do I talk to her about her “goals of therapy”? Can I search PubMed for a script? The books state that in medicine, there are 2 options for therapy: curative versus palliative—black and white in a world full of grays. What does “palliative” mean to a 36-year-old mother of 2, dying of cancer?

The literature told me to be frank, forthright, empathic, encouraging, and supportive. As I entered the patient's room, waking her as I usually did at 6:30 in the morning, I mentally rehearsed my talk. She had seen her CT scan; she had experienced, firsthand, the ravages of metastatic disease, as the cancer maliciously tore through her young frame, making reaching for a glass of water a chore. She smiled and said, “Good morning.”

After checking her vitals, I stuck with my script and asked, “What are your goals of treatment?”

“All I want is a way to clean myself after I make a mess,” she replied, pointing to her diaper. Cancer may have the power to ransack the body of its function, but my patient's humanity remained unscathed. I smiled back, at a loss for words, struggling to maintain my “doctor composure.”

“Also, I want to do my hair real nice when my kids come and see me.”

I nodded, again at a loss for words. PubMed did not prepare me for this, I thought.

Five days earlier, my patient presented to our emergency department, looking twice her stated age. Her legs had ballooned, as lower-extremity clots had decreased her venous return. Her urine output was near zero as the cancer had surrounded and choked her ureters. Her lungs, full of metastatic masses, failed to fully oxygenate and caused her to be tachypneic and dyspneic.

It was 7 weeks into my medicine clerkship, my first rotation during my third year, and responsibility to my patient overwhelmed me. The macabre pathophysiology, demonstrated by her metastases, took me back to my days as a second-year student absorbing nameless, faceless syndromes, associations, and conditions. Only this time, the pathophysiology had a name, face, and personality—all demonstrating a sense of humanity that a second-year curriculum could never convey. Although I could turn to renal physiology to make sense of her blood urea nitrogen–creatinine ratio, I had nowhere to turn as I tried to make sense of her questions: “Am I going to be able to walk by myself again?” “Are my legs always going to look like this?” “What should I tell my kids about my chances?”

Late that same night, as I prepared my presentation for attending rounds the following morning, I realized something: My patient is dying. How do I convey this to her? How do I convey this to her family? How do I internalize this?

After anticoagulating, correcting metabolic abnormalities, oxygenating, and assuaging her pain and dyspnea, we brought the oncology, nephrology, and palliative care departments on board, each offering its expert opinion on the best management options. With various specialists offering their opinion, we attempted to streamline her care. Her father noted, “The cancer doctors offered her a drug trial. It may not work, but if there is even a little chance, we have to take it.” My patient added, “What does ‘comfort care’ really mean?”

While attempting to mediate discussions about health care proxies or do not intubate orders, we found ourselves talking about her children, who had stayed in Puerto Rico, waiting to be sent airline tickets filled with hope for tomorrow. “They'e about to start school, one in high school, the other in middle school,” she said. “They'e both very smart.” The do not resuscitate/do not intubate form remained motionless on her breakfast tray. There it was again: her infectious smile. For a moment, we were anywhere but a medical ward, a place where the incessant hum and beeps of soulless machinery were nowhere to be heard, a place where 2 human beings could have a simple conversation, a place where 2 human beings could be human. The hospital can be an alien, inhumane place at times.

Two days later, my patient was sent to the intensive care unit after respiratory failure. As a new patient on the intensive care unit, my former patient and her family were forced to meet a new team of residents, interns, attendings, and nurses, all while facing the repercussions of end-stage cancer. The family searched desperately for familiar faces, all while their daughter's face took on the form of a stranger—the intubation, sedation, and pressors were taking their toll. As a medical student with a newly transferred patient, I had an “open slot” for a new admission. No debriefing, no meetings with the intensive care unit team; all they asked for was a transfer note for the chart. The intensive care unit team knew her blood urea nitrogen–creatinine ratio, urine output, and oxygen saturation. I'm sure they didn't know that my patient had 2 children, both of whom were very smart. The hospital can be an alien, inhumane place at times.

Every morning and evening, I made it a point to visit my former patient. A shell of her former self, I found her lying nearly lifeless, unable to smile because of the plastic tube secured in her throat. I would go there to simply hold her hand. She wasn't able to speak, but her eyes would plead for answers. At a loss for words, I grasped her hand more tightly, hoping by some sort of faith or magic, my “life force” could be transferred to give her what medicine could not: a day with nothing but her dignity and her children.

Two nights later, a code was called. That morning, I visited the intensive care unit and discovered an empty bed. I frantically ran to the visitors' area and found it empty. But I had other patients to take care of, as I was part of a busy service. Death may be a normal part of life in the hospital, but as physicians-in-training, we require more than just on-the-job training to deal with death and its many repercussions. Should I call the family? Did we do anything wrong? Is a condolence letter an appropriate gesture? Are there medicolegal ramifications for writing a condolence letter? Is it acceptable to cry?

I never wrote that letter. With a couple of keystrokes, my team and I were able to align the nuclear spin states of our patient to better delineate the extent of her cancer. However, when my patient's family needed me most, I was unable to put pen to paper and share their grief. I still think about my patient. I still regret my inaction.

To the family of my patient,

I am writing to send you my condolences on the death of your daughter, sister, mother, niece, cousin, and friend. I will never forget her ability to smile, and to make me smile, regardless of what obstacles lay in front of her. Every day, without fail, we always shared a laugh and a story. It was a privilege to take part in her care.

Your strength, dedication, and loving care gave her comfort in her final moments. Your strength, dedication, and loving care of her inspired me.

You will all be in my thoughts,

Vikram Padmanabhan

Postscript: As I accrue more experience on the wards, I have felt the pain of losing a patient more than once. The condolence letter has now become a clinical obligation of mine. It has allowed me to express my sympathy, acknowledge the bereaved, and recognize their loss. Furthermore, the condolence letter has allowed me to never lose sight of the humanity of the physician–patient relationship. Despite my initial misgivings regarding the writing of such a personal letter, the families of my patients have consistently responded with 2 words: “thank you.”