“And Ms. M. — I’m so proud of her!”
It was the first week of my oncology fellowship, and Dr. E., a senior fellow, was handing his patients over to me, as he was shifting from clinical work to research. He had emailed signout the night before, but this in-person meeting communicated all the nuance that a spreadsheet lacked — how Mr. R., for example, liked his chemotherapy scheduled around calving season. Having been a medicine resident just a week earlier, I knew minimal oncology. But this meeting was not about the science. It was about the stories.
“I was nervous because of her previous cancer,” Dr. E. told me. Twenty-odd years earlier, Ms. M. had undergone surgery and chemotherapy for breast cancer. “Chemobrain” had forced her to retire as a hospital technician, but she’d eventually recovered. She’d enjoyed the next 15 years, working as a teacher’s aide, and entered her 60s as a doting grandmother. She was thankful for this time but wary of intensive treatment. “I really didn’t like that stuff,” she would later tell me, shaking her head at the mention of chemotherapy.
In 2016, she’d developed a backache. The scan report a week later — multiple lytic lesions — had been unequivocal for cancer. It turned out to be a new cancer: lung cancer that had spread to the bones. Her body was racked with pain; her bones were brittle, some fractured. She quickly went from a vivacious educator, bending low to hug children, to listless and largely bedbound.
Dr. E., a first-year fellow in 2016, had evaluated Ms. M. in clinic. He faced a dilemma. Performance status is critical to oncologists’ decision making. The most robust patients receive the most potent chemotherapy, which offers the best shot for treating the cancer. Weaker patients fare poorly with chemotherapy, deriving little benefit and experiencing greater toxic effects. Debilitated, Ms. M. had been in no condition to undergo chemotherapy. She knew that, too: “No chemo, OK? We should plan accordingly.” Dr. E. empathized with her and treated her pain, but he told her the cancer might have a molecular alteration rendering it exquisitely sensitive to oral medications. The molecular results had returned 10 days later: “BRAF V600E mutation.” Dr. E. had been surprised. This mutation was present in just 1% of lung cancers. Oral medications targeting the same mutation in melanoma, where it occurred in a far greater proportion of patients, shrank tumors appreciably. Dr. E. had read the handful of reports of use of the medications for lung cancer. He’d consulted his mentors and discussed options with Ms. M. She agreed to try the medications off-label but had known they were in uncharted territory. “I want us to plan regardless,” she’d emphasized, keeping one eye on hospice.
“A week later, she was off pain meds,” Dr. E. recounted, “and she was back to school in a month” — she’d had a dramatic response. A few months after that, encouraging clinical trial results led to the medications’ approval for lung cancer treatment. Tremendous progress had been made rapidly, and Ms. M. had received the new standard treatment before it became standard. Dr. E. had every reason to be proud of both Ms. M. and his plan.
Ms. M. had returned to her routine. Six months passed, then a year. In most participants in the lung cancer trial, the medications stopped working within a year, but Ms. M. had an extended reprieve. A year and a half passed. Dr. E. wrapped up his clinical fellowship, and I started mine. That was when I met Dr. E., and a few weeks later, Ms. M., as her new oncologist.
I was immediately struck by her nurturing spirit. She inquired about my well-being and my family. I discovered her fondness for celebrity news and the British royal family. We discussed the royal wedding that had been held a few months earlier. We chatted for 20 minutes. Over the next year, we became good friends. Once, I caught her humming a Stevie Wonder song as I entered clinic. “Anything in particular making you happy?” I asked. She told me one didn’t need a reason to be happy. She confessed her love for Hallmark Channel shows, and I felt comfortable telling her I didn’t share her enthusiasm. In between the fun, we discussed advance care plans. “I don’t want to suffer. I want to be home, with family.”
Then there was a blip. Right-leg weakness prompted a brain scan, which revealed a spot. We revised our plan. Precise radiation therapy was directed to the spot. Ms. M.’s daughter began accompanying her to appointments, and we became friends as well. Ms. M. recovered.
Six more months passed. I was in India, dancing at a friend’s wedding, when I received an email message: “Ms. M. came in for seizures. MRI with LMD. Considering WBRT.” I exited the dance floor. LMD meant leptomeningeal disease — bad. WBRT, whole-brain radiotherapy with risks of toxic effects — bad. Unfortunately, our options were limited.
I reentered the United States a couple of days before sweeping coronavirus-related travel restrictions went into effect. We met in clinic. Ms. M. was in a wheelchair. I mentioned Meghan and Harry giving up their royal status. She managed a smile. “They should do what suits them,” she said. She realized she had limited time but told me, “I got more than 3 good years. I’m ready.” I ventured a last joke as her daughter wheeled her away to home hospice — “So, are Brangelina getting back together?” She giggled.
Her daughter called a week later, frantic. “Mom is not doing well.” Ms. M. was delirious, and I could hear her in the background, moaning in pain. The coronavirus pandemic had stretched all health care, including hospice, to its limits. The overwhelmed hospice agency was unable to evaluate her or transition her to inpatient hospice. I frantically called our urgent care center, asking whether Ms. M. could come in for symptom control. The nurse was sympathetic but warned me, “We may need to admit her. And keep in mind the no-visitor policy with coronavirus.”
For Ms. M.’s daughter, the options were to watch her mother in pain and delirium or to drop her off at the hospital. Conceivably, her mother could end up dying in the hospital. Ms. M.’s requests rang in my head: Let’s plan, no suffering, with family. And we had indeed planned. Our plans had evolved, but we had still planned: for targeted pills, for early goals-of-care discussions, for radiation, for hospice, for dying at home, comfortably, with family. Yet our plans were being thrown out the window by a virus.
Neither Ms. M.’s daughter nor I could bear to see her suffer. We decided to bring her in. “Good call, she looks awful,” the veteran nurse paged me. Ms. M. had to be admitted. The hospital was allowing limited visitors for patients who were actively dying, and back home, her daughter lay awake all night, phone by her side, hoping she wouldn’t get a call but ready to dash if she did.
Yet Ms. M.’s symptoms improved after 3 days, and her family picked her up. I shared their relief, but I didn’t go meet them — we were limiting nonessential interactions as the pandemic worsened. No final hug.
I updated Dr. E. the next day, as I always did on his former patients. He texted back, “I was on the inpatient service this weekend and caught up with her.” One silver lining of the pandemic, it turned out, was that senior fellows had paused their research to help with clinical care. Ms. M. and Dr. E. had reconnected after 2 years. “While it’s probably discouraged in the current situation,” he added, “I couldn’t help but give her a hug as she was discharged, as we did after every appointment.”
I smiled. We hadn’t planned for Ms. M. to see Dr. E. again. We hadn’t planned for that final hug. We hadn’t planned for me to tell her story.
But plans, it turns out, are only plans.