THE LAST GOODBYE

Today, I met with one of my dearest patients - Mr. D we will call him - for the last time.  His cancer was out of control, and I had run out of treatment options to slow it down or relieve his discomfort. Mr. D's visit and this news made both of us reflect on our four year journey together to combat his metastatic prostate cancer and how we had arrived to this spot.

In 2009, Mr. D first noticed back pain. He attributed this to moving some appliances and thought nothing of it. However, when the pain quickly escalated, he went to the emergency room. He expected to find a slipped disk or a pulled muscle. Instead, x-rays showed that his spine was riddled with lesions concerning for a cancer. His PSA blood test was sky high, and a biopsy confirmed prostate cancer.

I met him after he received surgery to his spine to prevent damage to the spinal cord, and I began to manage his prostate cancer with therapies that lower levels of male hormones.  We got two years out of that initial treatment, but then his cancer began to grow. We next tried additional hormonal therapies and then chemotherapy, which led to a remission. Unfortunately, that remission was short-lived and we moved on to a newer, more potent hormonal therapy. All the while, the patient was able to spend time with his friends and live a "near-normal" life.

He loved to fish on the Columbia River, and he often brought a cooler to clinic for me full of salmon or sturgeon. It was the best fish I have ever eaten, and I am not just saying that out of sentimentality; it was really that good.

In the past year, we went back to chemotherapy - this time at a reduced dose - and then a new hormonal agent. The benefits were limited, and the patient presented to the ER last month with new and severe back pain. The cancer was back and was threatening his spinal cord. If left unchecked, paralysis and loss of bowel/bladder control were certain. Although his cancer was advanced, I felt that the benefits of aggressive surgical intervention were worth the small risk of death during the procedure. His spine was stabilized, and his back symptoms did not worsen. He was released to a skilled nursing facility and recently made his way home to the Coast.

Today, I spoke to Mr. D about the crossroads we were at. Another form of chemotherapy could be tried. However, I expressed my concern that treatment might make him sick and feeling worse than he already felt. I explained that we had reached a point where medicine and treatments could not make his cancer go away but that I did not want to give up on making his symptoms go away. I told him that hospice was the best chance to help him feel as well as possible for as long as possible and that hospice would allow his family members to go back to being his family members rather than medical care providers. In essence, I told him that he was going to die and that there was nothing I could do to stop it.

I paused. He reflected. The silence was deafening. I waited for him to speak. He said that he got four great years with treatment, and he thanked me for everything that I had done for him. He said that he knew this day would come but that that knowledge did not make today any easier.

I told him that it was a privilege to be his doctor, that he and men like him are the reason why I come to work everyday, and that I would be with him for the entirety of his journey. We hugged and fought back the tears. I helped wheel him out of the room. It was clear what each of us had meant to the other. Then, we said our last goodbye.