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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 jco.org and search “Art of Oncology.”

Alison W. Loren, MD, MS, FACP

Alison W. Loren, MD, MS, FACP

I entered the examination room to find him pacing angrily. He gruffly cut off my attempt to introduce myself: “Doc, I’ve gotta get back on my ship.”

After a troubled childhood and an unfinished education, Kevin found his vocation by working on cargo ships. Recently hired by a new company, he was anxious to get back to sea, but an abnormal blood cell count at his preemployment physical upended his plans. Just 27 years old, he was diagnosed with essential thrombocythemia. The occupational physician would not clear him to return to work, and soon after, Kevin was found unconscious from a drug overdose. His oncologist referred him to an academic center, and that is how he came to meet me.

Kevin worked on shipping vessels all over the world and traveled for months at a time, docking at foreign ports, exotic and grim. He required treatment with hydroxyurea (because of extreme thrombocytosis and a myocardial infarction during his overdose), but his history was checkered with missed appointments and erratic use of his medicine. Monitoring him with blood tests while he was at sea would be all but impossible. How could I permit an 8-month disappearance on a ship to the Arabian Sea for someone with unpredictable behavior and questionable judgment? But Kevin was insistent, expressing both passion for life at sea and desperation for my blessing.

I asked him to compromise. He would take his hydroxyurea, and I would monitor his laboratory tests; in 3 months’ time, he would return to see me to reassess his seafaring safety. I was sure he would agree to this fair offer.

He exploded. Making liberal use of colorful profanities, Kevin conveyed that life at sea was his escape and his protection. His overdose, he growled, was directly related to the prohibitions issued after his diagnosis, to the frustration of feeling trapped on land, and to the onshore company he kept. As he spoke, it dawned on me that refusing to authorize his return to sea might be riskier than allowing him to go. So, I signed, and he went.

Surprising Disease Control

SOON AFTER our visit, I began to regret my decision. I felt bullied into signing his paperwork. I wondered, with a simmering, unpleasant mélange of resentment and humiliation, whether he would ever return to see me. Then he no-showed for his follow-up appointment, confirming my darkest thoughts.

A few months later, Kevin came back. He explained that he was at sea for our previous appointment, but he had been taking his medicine. “Sure,” I thought. I steeled myself for the barrage I expected to face, certain that I would have to refuse his paperwork when his blood cell counts betrayed him. Except they did not—they looked great. His schedule would be irregular, he said, but he would come to see me whenever he was back on shore, and could I please fill out his forms again?

“Is there such a thing as taking it too personally when your patient commits suicide?”
— Alison W. Loren, MD, MS, FACP

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That was in 2009. Kevin continued to take his medicine, his blood cell counts remained controlled, and he felt well. Every kept appointment astonished me, but to a lesser degree each time. Our early visits recapitulated the first, with Kevin evincing anger and threats. Whenever I saw his name on my schedule, I did an inner eye roll: Will he show up? Brace yourself for some attitude! But with each meeting, he was calmer and more respectful. Rather than cagily circling each other in a medical version of the prisoner’s dilemma (“I’ll let you go back to work if you take your medicine”; “I’ll take my medicine if you let me go back to work”), we began to have real conversations. He told me about his travels and asked me about my family. Gradually, I found myself beginning to root for him.

The last time I saw Kevin, he asked whether I had a patient of a certain description in the waiting room. I did not. “Good,” he said in his gravelly voice. “The guy is out there screaming at everyone. He’s high on something. He looks like he’s ready to hurt someone.” He paused, sizing up my small frame. “You stay away from him. If he comes anywhere near you, I’ll crush his skull.”

A streetwise guy giving a surly compliment, I thought with a smile. He was heading out to sea again soon. I made some recommendations about his hydroxyurea dose and sent him on his way.

Unexpected End

ON A WEEKEND not long after that visit, I was absentmindedly scrolling through e-mails when I saw a message from Sue, Kevin’s mother. The brief note took my breath away: “Kevin committed suicide on the 28th. He had sleeping pills filled on the 21st. He took all that were left and shot himself in the head.”

Shock and then sorrow. I’d come to think of this rough kid as a good soul who had found a way to survive. His path was steep and bouldered, but he came to an existence that—I thought—had saved him. I had allowed him to convince me that his peripatetic life soothed his psychological demons. Kevin depicted his life at sea as protection, and I believed him, but in fact, it provided inconstant shelter.

“Physicians willingly take responsibility for our patients’ lives, but how do we honor our obligation when psychological needs run counter to physical ones?”
— Alison W. Loren, MD, MS, FACP

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Next: Did I write that prescription? I replayed our last visit in my head. No, I do not think he asked me for anything for sleep. Hurriedly, I opened my laptop and logged into the electronic health record. Nothing. Relief was immediate but bittersweet. Was I blameless even though I did not write the script? Were there signs at our last visit? I replayed our interaction in my head. I reread my note until it was memorized. And if I had written the prescription, what would my responsibility have been? Certainly, I would have felt culpable, but perhaps I was taking this too hard, too personally. But is there such a thing as taking it too personally when your patient commits suicide?

“Dear Sue, I am so terribly sorry to hear this. I was fond of him and am very sad about this news. Thank you for letting me know,” I replied. I looked for an obituary, something more to add to my memory of him. Google came up empty-handed, but I found what I was looking for in his mother’s answer: “Thank you. Didn’t see this coming. Was a terrible shock. I know he thought highly of you. He was my baby, the youngest of four boys.”

Physicians’ Complex Responsibility for Patients

KEVIN’S DEATH forced me to reflect on my decision to allow him back to sea. Physicians willingly take responsibility for our patients’ lives, but how do we honor our obligation when psychological needs run counter to physical ones? What if I had refused to sign his paperwork and he had shot himself then? What if I had sent him on his ship and he had had a stroke?

I thought I had fulfilled my responsibility to Kevin as his doctor: to take care of the whole person. If he had died as a consequence of a clot or bleeding while aboard his ship, paradoxically, I would have been at peace with that. But his suicide haunts me. Although it was risky to sign those papers that allowed him back on his ship, I wished to honor his autonomy and became convinced that in doing so, I was saving his life. But I missed the most important sign of all, the moment he was most at sea. That responsibility is mine, even if the signature on the prescription was not.

At the time this article was published in the Journal of Clinical Oncology, Dr. Loren was practicing at the Perelman Center for Advanced Medicine in Philadelphia.


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