Sad oncology patients

1. Ms. X, a 40-something-year-old with a history of cervical cancer, now in complete remission. However, she had to have a complete pelvic exenteration, which would leave anyone's quality of life in a slump, and she kind of just never really recovered from a psychosocial standpoint, so she keeps coming into the hospital for pain and depression and other issues that aren't really related to her primary cancer anymore. I have to say, she's pretty pathetic looking: long, greasy hair, nasty hospital gown, colostomy bags and ureteral stents that she doesn't take great care of. Not helping matters any is her husband, who looks about 20 years younger than her (because he's healthy, showers, and gets haircuts, not because it's a May-December relationship), and who checks her into the hospital every couple of weeks when he gets tired of taking care of her and wants to have some time alone. Not appropriate. If he were any meaner, he would have already divorced her, but she depends on him for health insurance and his conscience is keeping him with her for now. He has already planned her funeral and has invited the office chemo nurses to it. Did I mention she doesn't have cancer anymore? He's asked about what happens if she stops eating and refuses her TPN, even though she has expressed no desire to stop eating or stop her TPN, and yesterday he asked for a hospice consult. The woman isn't dying, she's depressed. But that (or her husband) is going to kill her anyway.

2. Ms. Y, a 50-something-year-old with a history of cervical cancer who came in late last week for uncontrollable nausea and vomiting. She hadn't eaten anything in two or three days, had dropped from 85 pounds to 75, and refused to eat in the hospital, complaining of continuous nausea despite anti-emetics and pain meds. She refused to entertain the thought of a temporary feeding tube down her mouth, and refused TPN as well. She was really sad and pathetic looking, remaining curled up in bed, looking determined to will herself to die. After a couple of days of this and numerous conversations about why she needed to start eating, we gave her Marinol, and within 24 hours, she was a new woman. The last time I saw her, she was sitting up in bed, drinking a soda and Boost and eating a humongous chef's salad, asking to be discharged. Who knew the munchies could be so effective?

3. Ms. Z, whose cancer history and admitting diagnosis I never really understood, because the students were asked not to see her and she was only in the hospital for about 24 hours. I believe her cancer had recurred despite numerous cycles of chemo and she was probably admitted for nausea and vomiting or something like that. The attending ended up having the end-of-life conversation with her, and they all decided she would go to hospice. (Hospice, in case you don't know, is for people who have an estimated six months or fewer to live, and they receive palliative care only, either at home or at a long-term care facility.) It was fairly straight-forward; she was OK with the decision to enter hospice and I think, based on her records, pretty happy to be done with trying to fight an incurable cancer. The saddest part was that while we were sitting in rounds that afternoon, her nurse poked her head in to say that she had eaten a whole cheeseburger (an accomplishment). "Yay!" said the physician, "She can have all the cheeseburgers and ice cream she wants!" It struck me that she was now allowed to eat anything she wanted, because she was just waiting to die, and that was very, very sad. Even out-of-control diabetics are allowed to eat Twinkies once they enter hospice, because it becomes a "big picture" situation.

So my two weeks with GynOnc are over, and I got 12 full hours of sleep last night to celebrate. It was really interesting, pretty fun, educational, and of course exhausting. As luck would have it, my last day was the worst, a full 16 hours long. My take-home impression is that in-patient oncology isn't actually all that sad and depressing, because the patients are acutely ill and you're focused on the short-term treatments, not long-term discussions of life and death and their chronic conditions. I didn't get to see any of the oncology patients in the office, where more of the somber conversations would take place. Plus, not all the patients are as sick or complicated as the three above; plenty of them have minor disease, are healthy other than having cancer, take good care of themselves, or have really positive attitudes. Even if I did go into Ob/Gyn, I don't think I would do GynOnc, but nothing has been ruled out completely yet, which means I still have about seven months to figure out what I want to be when I grow up. Monday I start two weeks of following a private practice physician; she'll either let me do nothing at all and I'll just be shadowing, or else she'll let me do a lot and I'll be helping with surgeries and deliveries. I hope it's the latter!