When do you stop fighting?

September 2008.

He was hunched in his wheelchair with a blanket on his thighs, covering his right lower leg amputation from twenty plus years ago. Thin, he was very thin. He waved at me and smiled a weak smile, brown blotches on his teeth. I felt a pinch in my heart as i smiled back and shook his hand, then proceeded to my chair where the computer sat before me.

***
2007.

"I need refills on my Vicoprofen."

That was the only thing he needed to say for me to roll my eyes upwards and groan inside. But of course i did not do that.

"What for?"

"My pains."

"Where?", my one word questions showed that I was not in the mood. I have had patients shout and cuss at me, even walking out on me for not giving in to their addictions.

"here...here...here...everywhere."

Yeah, i've heard this a gazillion times and i even have a spiel for it ready.

"Mr. B, i have to tell you something before we continue. Very few of my patients, and i mean very few, are on narcotics. I have difficulty giving out habit forming drugs to patients i have only met once. Let me go through your history so we can see what's really happening. "

Multiple office visits for nonspecific pain. Missed at least 3 appointment referrals to the pain clinic because he says he "lost his insurance" and had just gotten on disability. At 44. On disability at 44 years old. He did not look weak at all. Except of the amputation on the right leg, this man could walk on his arms. All the more i did not want to give him his medications.

"Sir, I would like to discontinue your Vicoprofen and start with plain Ibuprofen."...i was waiting for a violent reaction which almost always comes after those lines.

"Ok."

I looked at him puzzled. I was expecting him to say that he was allergic to all other meds but the narcotics, or that you-do-not-understand-because-it's-not-you-who's- in-pain line that a drug seeker would usually throw at me.

I felt ashamed of myself.

"I'm sorry, sir, it has been a long day. Excuse me for my demeanor."

"that's alright."

"Let me check your labs, ok? It looks like they need updating. If something comes up, i will call you to let you know."

"Sure, doc. Thanks."

****
Labs drawn. Unusually high calcium. It was real pain. Multiple nodules on his lungs on chest xray. CT scan verified the nodules and described it as most likely spread from cancer somewhere........the Right kidney. Biopsy showed renal cancer.

I gave him his vicoprofen.
Surgery wanted to take his kidney out.

"Tell me if you would you want to go through this, T?" i called him by his first name now. With the spread his prognosis was poor.

"Yes, i do."

***
May 2008

Right nephrectomy done. He developed a large blood clot in his IVC . He also developed liver and respiratory failure and required intubation in the MICU. When he came to and eventually extubated, he developed another large clot for which he needed blood thinners. I visited him in his room on the 3rd floor.

"Hi, T. How are you?"
"I've seen better days."
"I know."
"i don't think i should've gone through this..."
"I'm sorry it had to be me to tell you about the cancer."
"the oncologists were impressed, really, how you found it and all. They told me i had a good doctor. I bragged about you."
"Thanks, T. i still feel that maybe i should have talked you out of the surgery."
"well...it's done..."

He did not show up for follow up. I called his house and left messages on his voice mail. He showed up a month later. I noticed his increase abdominal girth and his swelling legs. This was not good. He was just readmitted for altered mental status. CT of the head showed multiple lesions in the brain....more spread. He was supposed to get chemotherapy after his nephrectomy. Now he needed radiotherapy.

***
September 2008.

He was hunched in his wheelchair with a blanket on his thighs, covering his right lower leg amputation from twenty plus years ago. Thin, he was very thin.

He mumbled something...

"what's that, T? you saying something?", i leaned forward.

"i don't think i'm gonna make it." he whispered while looking down at his hands.

there was a tightness in my throat. i placed my hands on his lap.

"it's ok if you don't want to do this, T....it's ok....there's nothing wrong with not getting further treatment. it's ok...", i was running out of words to say...

He continued to stare at his blanket.

"i want to do something for you, T. I want to make you comfortable and pain free. I don't want to cause more pain, or harm or discomfort. I don't want you to spend more time in the hospital than with your family at home. we can cancel the treatments planned and just make you stay home, if you want that. I'll make sure you're comfortable...would you want that, T?"

"yes...yes." He nods.

I could not take it anymore. I needed to get out.

"i'd like you to meet somebody. She will talk to you about care that i would like you to receive. It will involve other health workers but i will make sure that i will still be much involved in your care. I promise you that. I will still be your doctor. I will visit you. "

"ok"

"Her name is Leah. She's the social worker who's gonna arrange everything for us. Would you want to talk to her?"

"Yes."

I walked out the door and headed towards the social worker's office. Before knocking, i turned around and went into the procedure room to wipe my tears. I headed back to the the social worker's room, trying to sound composed but my red eyes and my cracking voice betrayed me.

"Leah, give me the best hospice care team you've got."

*****