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The ASCO Post is pleased to reproduce installments of the Art of Oncology as published previously in the Journal of Clinical Oncology. These articles focus on the experience of suffering from cancer or of caring for people diagnosed with cancer, and they include narratives, topical essays, historical vignettes, poems, and photographic essays. To read more, visit ascopubs.org/journal/jco.

Mikkael A. Sekeres, MD, MS

Mikkael A. Sekeres, MD, MS

Despite our methodic natures or measured critical thinking, the choices we make at life’s crossroads often eschew science. That is, notwithstanding the efforts we go through to carefully balance the advantages and downsides to important decisions, in the end, we let emotions guide us and work backward to justify ourselves rationally.

My first day of residency in Boston, we sat in a conference room that smelled vaguely of Indian food, the remnant of lunches from past noon conferences. We were handed our rotations for the next year, the schedule that would determine whether we would be able to join our families for Thanksgiving, go out to parties on New Year’s Eve, or even wake when our bodies told us to on a given Sunday morning. I was focused more on where I would have to report the next morning: the medical intensive care unit—the MICU, or Deathstar, as the older residents liked to call it. I had never rotated through an MICU as a medical student and thus was completely unfamiliar with how to manage these critically ill bodies masquerading as sentient human beings. And I was on call the first night.

‘The Longest Day of My Life’

This would turn into the longest day of my life. I met my junior resident, Dave, the person who would share my call nights, at 7:00 AM, and he helped me make it through rounds with the MICU staff, fellow, senior resident, two other junior residents, and two other interns. To put it more plainly, he did all the work of writing notes, making decisions about patients, and placing invasive lines, while I ran errands for him and was thrilled when I could successfully locate an x-ray in the catacombs of the radiology department.

As night fell, we rounded out, during which the other intern-junior pairs told us about their patients and then took their leave. It was a scene straight out of a World War II movie, in which the company is forced to abandon the two guys whose legs were shot up, leaving them with a certain amount of ammunition to fend off the advancing Germans. They always say goodbye and promise to come back to retrieve the guys the next morning—if they survive the night, which everyone knows is highly unlikely.

Saying Goodbye for the Last Time

Among the usual medical disasters we would care for that night—the old people with consuming pneumonias, the patients with dissecting aortas, or hearts that beat at one-tenth their usual capacity—was a woman, a pediatrician from a nearby hospital, who had widely metastatic ovarian cancer and whose lungs were filling with fluid. Initially, she was to be intubated and placed on a respirator, but she changed her mind, deciding instead to live her last hours breathing air on her own, unassisted. She was in her early 40s, and her appearance in our unit had consumed our team’s emotions that day. It didn’t help matters when her son and daughter, ages 10 and 8, came in to say goodbye to her in the evening—we all knew this would be the last time they would see her. Each of us in turn, doctors and nurses, sought refuge off the main floor to check the hitch in our breathing or to cry outright in private.

Cards for Every Occasion

Her husband escorted their children away and returned a couple of hours later with her best friend, now carrying a CVS bag. As I was doing my rounds, checking vitals on patients to dutifully report back to Dave, I glanced into her room and saw her husband standing, hunched over her bed, holding a clipboard as she wrote something. I made it back to our conference room.

“Hey Dave, what’s going on in there?” I asked, gesturing to her room. By this point of the day, I had proven myself to be so utterly helpless, I no longer even worried about asking Dave completely idiotic questions. He was my lifeline, my only source of truth. If I had even time to go to the bathroom, I probably would have needed his assistance with that, too. He looked at me blandly but without prejudice.

“She’s writing out cards.”

“3 × 5 cards?” I asked. I had a pocket full of them, each with a different patient’s information written. The only cards I could picture.

“No, birthday, holiday cards—those types.”

Birthday cards, holiday cards, graduation cards, cards for every occasion she could imagine. Cards for bar and bat mitzvahs. Cards for Halloween. Cards for the next 10 years for her son and daughter. Cards so she could be a part of their lives. Cards because she was so proud of them. Cards so she could live those years with them over the course of her last night on earth. Cards so they would never forget her.

I was up all night, caring for others and watching her stay up all night, writing—sometimes her husband holding the clipboard, sometimes her friend. The sun rose over the Charles River, she finished, and as her breathing became more labored, she asked that her morphine dose be increased.

Reasons Behind Career Choice

Over a decade has passed, and I still think about her all the time. I wonder if I would do the same for my children, now that I have them, or how I would deal with this cache of missives from another world, if I were her husband. I also think of her son and daughter—did they look forward to getting these cards throughout the year, or did they dread them? Did they save them? As a parent, I would hope so. But maybe her uncertain handwriting during her final hours reminded her kids of the time when she was sick, so they rejected the cards for earlier, happier memories.

I became an oncologist. Ironically, years later, Dave himself developed cancer and called me for help. I can provide perfectly rational reasons for my career choice, including the fascinating pathobiology of the diseases, the opportunities for translational research, or the prospect of conducting clinical trials of novel agents.

But, really, it is to have even a glancing connection to people who face these terrible diseases with dignity and, in so doing, give value to the lives of everyone around them. It is because of that woman, who wanted to have a say after her death. 

DISCLOSURE: Dr. Sekeres has served as a consultant or advisor to Celgene, Millennium, and Syros Pharmaceuticals; and has received institutional research funding from Pfizer and Takeda.

At the time this article was published in the Journal of Oncology, Dr. Sekeres was working at the Cleveland Clinic Taussig Cancer Institute.

 


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