Abstract
I
My next patient is Mr. W, a 54-year-old man. I saw him last week for the first time. He has advanced-stage cancer and was at the clinic to discuss the next step of his treatment. Unfortunately, we are out of treatment options at this point. During his appointment the previous week we had gently suggested hospice, which Mr. W immediately rejected. He insisted on receiving more chemotherapy, despite having failed three different regimens previously. Other than having “this cancer,” he felt healthy, and he talked about his future plans once he has beaten the disease.
We agreed to see him again this week to see how he feels. Although we had discussed the possibility of one more round of chemotherapy, we did not really believe that it would help.
As I replay our previous week's conversation in my mind, I wonder how this day's conversation will go. I knock at the door of the exam room, pause for a moment, and then enter the room. It is immediately apparent that things have changed drastically compared to last week. A woman sits on a chair next to Mr. W, who is in a wheelchair today.
I greet them and walk over to Mr. W. “How are you doing today, Mr. W?” I ask as I sit down next to him. Mr. W does not react. His shoulders are hanging; his body is slumped forward; and his left cheek rests on his hand with his eyes fixed to the floor.
The woman, who accompanies him today, introduces herself as his sister. She tells me that her brother did not do well during the last week. He was not able to eat and he felt very weak.
I turn again to Mr. W. I put my hand on his and ask him if he has pain. Mr. W slowly lifts his eyes. There is an endless sadness there, and I can see that all his hopes are gone. He shakes his head very slowly. “No, no pain,” he whispers, “just weakness.” It is as if he no longer has energy to speak even these few words. We talk only briefly before I leave the room to talk with my attending.
When my attending and I return to the room together, Mr. W is shaking his head as he looks down at the floor. “Doc, I want no more chemo. I can't take it anymore.” My attending and I look at each other. We silently agree that he is not in a condition to be given chemotherapy.
I kneel down and touch Mr. W's hand. He lifts his eyes and looks straight into mine. I see tears rolling down his cheeks while he swallows and remains absolutely silent. In that fraction of a second I am dumbstruck by the knowledge that Mr. W has come to the realization that he has reached the end of the road: He is no longer a patient whose disease can be treated.
Suddenly Mr. W starts talking. He inquires about hospice and talks about not wanting to burden his family. Tears continue rolling down his face. “But I am still young, doc, too young to die.” I look at his sister. She, too, cries silently as she tries to hide her tears from him.
Overwhelmed with emotion, Mr. W begins to cry so violently that his body starts shaking. My attending and I look at each other, but there's nothing meaningful that we can say to either Mr. W or his sister. I put my arm around Mr. W's shoulder; this is all I can offer him.
After a few moments I stand up and leave the room with my attending. As we talk in the conference room I wipe away tears from the corners of my eyes. My attending notices and says, “You don't need to feel ashamed about your tears.”
I am struck by her words. Although I realize that her intent is to be supportive, I am surprised as to why she felt the need to say what she had just said. I am not ashamed of my tears. But I am surprised that the word “shame” has come up in this situation. How can feeling a fellow human being's pain and empathizing with it ever be perceived as something to be ashamed of? After all, does the feeling of shame not arise from the perception or an awareness of having fallen far from the ideal, of not having been perfect, and of having shown a certain degree of weakness? Does she mean that having no treatment for this patient is something that might cause me to feel shame? We both know that medicine, as advanced as it is these days, still has its limits; these should not be viewed as an individual physician's failure.
Or was my attending's statement a reaction to her own feelings? Maybe she felt for some reason shame and transferred her feeling on me, or had she herself once shown her feelings and was scolded or ridiculed by a superior or by her peers?
Can it be that in our profession feeling for or with the patient and expressing those sentiments is sometimes considered inappropriate and an expression of weakness?
What kind of physician and what kind of person would I be if I remained indifferent and untouched by Mr. W's anguish? Or did I appreciate the intensity of his sadness only because for a tenth of a second his eyes met mine and because I chose to not let him be alone by looking away in that decisive moment when he realized that his end is near?
From my attending's choice of the word “shame” I realize that shame consciously or unconsciously seems to play an important role for some physicians, guiding them as to what part of themselves they can safely show and share with patients and co-workers, and what part they should rather keep to themselves. “Shame” may be a feeling that helps them differentiate and maintain professional distance, and at the same time, feel closeness to a patient and his or her suffering.
One week after his clinic visit, Mr. W dies. When I learn about his death, I again have tears in my eyes, not out of pity for a patient who had a terminal disease, but rather for the betrayal that he must have felt by life, when he reiterated that he was too young to die, and for the sadness that I saw in his eyes as he understood that the hopes and dreams, which had filled his heart, will remain unfulfilled.