“If I am to care adequately for the sick…”—Lessons from Pancreatic Cancer

On November 25, 2005, my mother died of pancreatic cancer—a death that represented the culmination of a courageous battle against a near-undefeated foe. Losing my mother was crushing. It created a disorienting and suffocating void in my life. Lacking direction personally and professionally, I felt paralyzed and aimless. In the years since her death, I have juggled life as a husband, father, and physician attempting to establish a medical career. At the same time, I have long struggled to understand my relationship with the disease that cost my mother her life.

Upon my medical school graduation nearly three decades ago, my parents gave me a beautiful plaque of a modernized version of the Hippocratic Oath. Their gift commemorated a landmark educational accomplishment, and no doubt reflected pride in their son. Days later, I drove across the country to embark upon my internal medicine residency. Over the arc of my medical journey since, the plaque has hung on the wall of various work offices, gazing over my shoulder and career.

Shortly after my mother died, I admitted a woman with painless jaundice. She was about the same age as my mother at the time of her untimely diagnosis. I explained the likely cause of her illness to this matriarch and her anxious family. I swallowed the lump in my throat and my pity for her, knowing what lay ahead for everyone in the room and took note of the gnawing pit in my stomach as I recalled the familiar “mass…pancreas” imaging report.

We struggled to coordinate timely outpatient follow-up and care for someone who lacked medical insurance. I understood her financial limitations and could envision how this might play out. In the end, I excused myself from the room, rushed into the nearest bathroom, and wept. I understood her financial limitations and could envision the truncated life that lay ahead, with its stark contrasts to my own family’s full access to care and resources. Through her unconditional love, altruism, and benevolence, I was provided a guiding vision as a clinician. I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability.

Five years later, I cared for a man admitted with bleeding complications caused by anticoagulation for pulmonary emboli driven by his underlying pancreatic cancer. He was a highly successful investor and entrepreneur; both he and his wife had clear expectations that our medical team would heal him completely and provide an expeditious return to their life pursuits, with minimal interruption. However, their expectations would quickly prove unrealistic. Cancer had plans of its own, and, despite our best treatments, his health declined rapidly.

Conflicting emotions stirred within me as I tried to reconcile our provision of escalating, near-futile medical care with medical reality. Entitlement? Unrealistic expectations? In the days ahead, I spent inordinate amounts of time communicating evolving facts and professional recommendations. He and his family repeatedly wondered aloud why we could not make him better. In conveying the certainty of his decline, I shared with them—through welling eyes—the story of my mother’s cancer journey.

After the patient died in the hospital two weeks later, I felt curiously “lucky” as I recalled my mother’s fortune in avoiding a single day in the hospital during her 17-month illness. My mother and family were thus spared witness to similar drama. We avoided a helpless decline within the four walls of a hospital room with my mother tethered to machines. We maintained a modest sense of clarity and control. We evaded an impersonal death among strangers. Patience, resiliency, resolution. I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

More recently, a middle-aged man with ashen skin and a hollow gaze peering through gaunt eyes was admitted to my service with progressive weakness. It was quickly evident that I had seen this story before, one that surely represented an impending revelation of pancreatic cancer progression. As discussions evolved from findings of the initial workup to the minimal therapeutic options available, I was struck by the patient’s serenity.

“It is time,” he expressed unambiguously without uttering a word. He exuded a sense of peace and illustrated how the story can and should unfold. He appeared to embrace his imminent death. Patients are often more ready for the truth than we are as physicians. Vulnerability, honesty, tranquility. I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.

Three patient encounters exposed patients with their “stuff” versus me with mine. More accurately, their stuff is in addition to my stuff, representing patient chapters from diagnosis to death scripted over a decade, illuminating an enduring story. The collective impact of this unfortunate trio ultimately triggered a crescendo in my own self-understanding.

Time has afforded me first-hand experience of the tortuous journey of pancreatic cancer and its indiscriminate nature. It’s a disease that afflicts people rich and poor, insured and uninsured, supported and alone. It traverses all demographics, family constructs, and strata in life. It unmasks helplessness and anguish for patients and their loved ones.

This singular disease—and all that comes with it—advances the ethical mandate of anyone who has taken the oath, ambiguously blurring the role between healer and healed. My professional responsibility lies in treating not only the gowned patient under a sterile bedsheet with an IV in their arm but also the human being, inevitably afraid, whose life outside the hospital is left suspended.

Patients reciprocate in subtle and profound ways. With gratitude, I acknowledge all who have unwittingly shared their intimate experiences with illness and lain bare genuine human qualities in times of their greatest vulnerability. Through an evolving reckoning along my own journey, I have come to slowly “make sense” of my own loss, the death of my own mother at too young an age.

These shared experiences united my heightened empathy as a clinician with an amplified sacrifice as parent and husband, a confluence of my life as a doctor with my life as a son, husband, and father. A bidirectional relationship has emerged between the personal and the professional- each giving to, and sometimes taking from, the other.

Illness and death spare no person. Modern medicine cannot cure all. My professional and personal journeys over a decade and a half have sharpened my vision of dying and death through a clearer lens. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty.

Today, as I look up at the plaque in my office, it is with gratitude and pride. I have gained a deeper understanding of the true significance of my parents’ gift and my oath. I have been awarded a supreme lesson to honor the life and death of my mother. She instilled in me empathy, sacrifice, and patience, traits that define my role as clinician beyond any textbook or lecture. I am left with eternal lessons in humility, resiliency and hope, and the indelible imprint of love and family. Patient, doctor, mother, son. That I will lead my life and practice my art in uprightness and honor, it shall be for the good of the sick and the well.

Acknowledgements: The author wishes to acknowledge and thank Drs. Micol Rothman and Mark Kissler, University of Colorado, for their insight and contributions to this manuscript.