Ilana Hellmann, MBBCh
It was a hot and humid Tuesday in July, and I distinctly remember being grateful for the air conditioning in the pastel-shaded waiting room of the oncology outpatient clinic. My father sat silently beside me. We knew this room well, as we did the doctor we had arrived to see. He had been my mother’s oncologist until she had passed away just over a year previously from metastatic breast cancer. Dad remembered him being kind yet direct and had requested he be his oncologist now that he needed one.
I watched his hands fidget with the slip of paper bearing the number that would be called over the loudspeaker. My father was 84 and a retired university professor of statistics. He spoke seven languages, and his friends called him the encyclopedia, as he was an endless fountain of knowledge in history, politics, literature, art, etc. His number was called, directing us to a room we had been in many times before. After some small talk about my late mother, Dr. C addressed my dad and slowly went through the history.
A Diagnosis of Metastatic Squamous Cell Carcinoma
He had had surgery for a squamous cell carcinoma on his scalp along with a skin graft 6 months earlier. About 2 or 3 months later, he complained of pain in his right hip, which seemed to worsen by the day. After some imaging and assessment by an orthopedic surgeon, a diagnosis of osteoarthritis was declared, and the treatment recommended was a total hip replacement. The surgery was performed, and my dad, who had been suffering from extreme pain, felt immediate relief. He was delighted with the results of the procedure, delight that dissipated in an instant when the pathology report came back: metastatic squamous cell carcinoma.
He had been quickly referred for a course of radiation therapy, which had been completed. This meeting was intended to discuss further treatment. Dr. C gently explained my father’s cancer was not curable, and there was no good treatment available for him at that time.
I do not really remember much of what was said after that. I found myself thanking him for his time and helping my father to the car. The drive home was awful, with awkward silence broken only by a discussion about what he was going to have for lunch. We both pointedly avoided talking about the meaning behind Dr. C’s explanations. I was stunned. I felt like my father had been fired by his doctor and I had been left to deal with the consequences. I felt alone, abandoned, and betrayed.
Saying Goodbye
The next few days passed quickly, as I juggled my busy hospital schedule with family dinners, school runs, and the sporting activities of my three boys—the oldest of whom was 11 at the time. The weekend came, and on Saturday morning, my husband and I planned to meet friends at the local swimming pool, as we so often did in the hot summer months. Leaving him to clean up honey and pancakes, I went across to the apartment opposite ours to say good morning to my father and tell him we would be gone for the better part of the day.
He was sitting up in bed and said: “Before you go, please bring me my phone book.” He still used an alphabetized phone book, mostly in my late mother’s handwriting. I found the book and held it out to him. “Find David Green’s number” he said, which I did. “Dial it please,” he said, while looking for his glasses on the bedside table. I dialed and handed him the phone. I then listened as he greeted David—an old colleague from his years in academia. Dad had not spoken to David in many years. He explained he had cancer and did not have much time, but he wanted David to know how much he had enjoyed working with him and to thank him particularly for his contribution to an article they had published together in the past.
I got up to go, and, seeming not to notice, he asked me to dial the number of another friend. Realizing this was going to take some time, I called my husband and told him to take our boys to the swimming pool without me. I sat down next to Dad on his bed and dialed number after number. My parents had lived in a few countries, and my father’s academic career had connected him with people all over the world. Over the course of almost 6 hours, he spoke to friends, relatives, old neighbors, and many work colleagues. He had a personal message for every one of them and started each conversation with a clear and brief explanation of the circumstances of his call. There were some people who were not home for his call, and he left long messages on answering machines. Those 6 hours were cathartic for both of us. It was sad but also terribly beautiful and filled with my dad’s signature black humor.
Once we had contacted everyone in the phone book, he continued his mission and gave me a list of people he wanted to be present at his funeral, as well as a second list of those he would prefer not to be there. Then, he handed me an envelope that contained a substantial sum of money. “This,” he explained, “is for the gentlemen who come to take my body.” My mother had died at home, and he remembered the two ambulance men who had come to take her body to the morgue after she had passed. He had been struck by the difficulty of such thankless work and wanted to make sure they were appropriately compensated.
Very soon after that Saturday, my father had a seizure and was diagnosed with brain metastases. As dad had made it very clear that he wanted palliative care and no admissions to the hospital, Dr. C connected us with the services of home hospice care. He deteriorated rapidly and died at home, as he had wished, 3 months later. The money in the envelope was duly delivered to its intended recipients, and there are some people who were not at his funeral.
The Art of End-of-Life Discussions
I have often gone back to the conversation in the oncologist’s office on that July morning. Oncologists conduct end-of-life discussions with their patients every day. How does one tell the patient the truth without taking away every ounce of hope? Do all patients have to know they are dying? I had never thought about the immediate consequences of what I say to my patients and their loved ones until I had to get my dad to the car and spend those eternal 20 minutes with him on the drive home.
Bad news is difficult for those on the receiving end but no less so for those given the task of delivering it, especially when it concerns a terminal illness. There are some physicians who avoid telling their patients their disease is terminal altogether. In not telling patients of the terminal nature of their cancer, are we protecting them or ourselves? And are we preventing them from being able to use the time they have left in a way they would wish, with the knowledge that time is limited?
There are those patients who cannot or will not talk about death. Knowing how much to say to each of our patients, and choosing the appropriate words, is an art. The task entrusted to physicians of giving bad news is both an immense privilege and a grave responsibility.
My father received a brutal gift that day. But brutal as it was, it was a gift that enabled him to part, to make peace, and to prepare for his coming death. I have since had countless conversations with my own patients about their imminent demise. I constantly remember my father and that special Saturday. My memories are of tears, and of laughter, and most of all, of a sense of closure for both of us. I hope I am able to give my patients their truth in a way that will make it as much a gift for them as it was for him.
Listen to a podcast by Dr. Hellmann at aoopodcast.libsyn.com.
At the time this article was originally published in the Journal of Clinical Oncology, Dr. Hellmann was working in the Hematology Department at Meir Medical Center in Kfar Saba, Israel.
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.
