WA News Guest Opinion / Editorial What My Patients Teach Me
What My Patients Teach Me
Written by Dr Nick Lan
Tuesday, 29 August 2017

25082017-ICU-Drip-HospitalThis year I have been heavily involved in the care of two patients aged in their 20s, both with stage IV cancer. Seeing these young patients with terminal illnesses has impacted on how I treat patients (Patient One) and my own outlook on life (Patient Two).

Patient One was diagnosed with an extremely rare metastatic carcinoma. I was there when she was first diagnosed and when she died – all within my oncology registrar rotation. I saw the disease progress rapidly on her scans, despite chemotherapy. I witnessed her strong resolve to do whatever it took to stay alive.

We sequenced her whole genome, looking for targetable gene mutations but found none. We discussed her case with experts around the world, hoping for other treatment options, but were disappointed.

During the last few weeks of her life, she requested to fly across Australia to participate in a research study trialing new immunotherapy drugs as a last-resort treatment for end-stage cancers with no targetable mutations. She ended up enrolling in the study but died shortly after returning to Perth for more chemotherapy.

Patient Two was also diagnosed with an aggressive sarcoma. I was the cardiology registrar when he was referred to me late at night. I went to the ED and found a fit young man smiling cheerfully at me with his father by his side. He was a hard-working university student, a non-drinker and a non-smoker. He reminded me of myself, and that was scary. He seemed fine except his heart rate was between 130 and 160, in atrial flutter. I tried medications to decrease his heart rate but that only lowered his blood pressure. A brief echocardiogram showed a massive pericardial effusion and a mass in his myocardium. I admitted him immediately to the CCU and he underwent insertion of a pericardial drain. Despite having a terminal diagnosis, he remained positive and never complained.

The impact of patients?

Treating Patient One caused me to reflect heavily on the ethical principles of patient care. As the registrar under an oncologist, I was initially not involved in making treatment decisions and, hence, safeguarded from that element. However, her treating oncologist was away when she was admitted to hospital with increasing cancer pain and I found myself having to make many treatment decisions.

She made it clear to me that she wanted all treatment avenues explored. I spent hours each day liaising with genetic specialists and oncologists around Australia and America. It didn't seem fair to me that someone so young must die of a rare cancer. I wanted to do everything I could, as her doctor, to help her. I was of a similar age and knew there was still so much life to be lived. If I were in her position, I would want to try any treatment option.

When she requested to go interstate for the trial, she already had widespread metastatic disease. Her risk of pulmonary embolism was high and her condition was deteriorating quickly. Furthermore, her coagulation profile was becoming deranged. The risks of the liver biopsy were substantially increased. She still wanted to go. Her mother still wanted her to go. I distinctly remember the moment she told me that she “was not going to give up”.

Logically, there seemed no point in going. What was the point of spending your last few weeks on earth travelling to a different city in discomfort, to have a risky biopsy with little hope of treatment? We are taught to do no harm. Woul d me encouraging this trip constitute harm? Would entering the trial benefit the patient? Should such a sick person even be enrolled into a clinical trial?

Yet this patient wanted to live. Shouldn’t we at least let her try other options? Whatever we were doing now clearly wasn't working.

As doctors, we should give our medical opinion and allow the patient to decide on the treatment plan. In the end, I complied with her wishes and organised her enrolment in the research trial. To this day I still question whether it was the right thing to do.

Patient Two was the reverse. If he was angry about his situation, I couldn’t tell. He did what we advised and never complained. I was deeply sorry for him and his family and everyone on his care team felt the same way. We knew he was scared and, although he never expressed it, we knew he didn’t want to give up either.

His case illustrated to me how fragile life can be and how it can change in a moment. It made me contemplate the most important things in my life and how I should be spending my time.

Life and death is something that we deal with every day in our profession. We don’t learn much about it in medical school, we kind of just get used to it from the job. Being a doctor can be emotionally taxing. This case served to remind me not to become too attached to patients.

Impact on my professionalism?

Both cases have encouraged a deep reflection on the ethical issues in medicine and about the ethical framework in clinical practice. It has taught me the importance of meaningful communication to engage with patients, to be respectful of their rights and to empower them to make decisions about their own lives.

I discovered empathy and my desire to help others. However, I also discovered that I have a way to go. My strong emotional investment in their stories and my lack of experience to guide their decision making were weighty issues. I believe that only time and experience will help improve my skills in this area.

By Dr Nick Lan