Pity is a horrible feeling to have

I am currently on the solid oncology service (think lung cancer, breast cancer, colon cancer, etc... basically, anything other than leukemia and lymphoma). I recently took care of a lady that taught me how much my own preconceived notions affect my medical decision making.

When I first met Ms. M, she was clad in hospital garb -- she was barely covered in a faded, wrinkled hospital gown. A large central venous catheter, the size of a number two pencil, was attached to a vein in her neck and held in place by gauze and tape that were covered with dried blood. Her scalp was covered in some places with short, stubbly hair and was completely bald in other places. She was lying in bed staring off into space while the nurse fiddled with the catheter in her neck.

When I walked into the room and introduced myself she gave me a weak smile. She looked like she was about 60 years old. In fact, she was 40 years old. Just a few years ago, Ms. M had been diagnosed with breast cancer. Originally, the cancer was localized to just one breast. She underwent surgery and lived worry free for one year before the cancer returned. The recurrence was confined to the same breast. However, this time she underwent bilateral breast removal. She also underwent chemotherapy and radiation treatment. The worry free period this time around lasted just a few months and then the cancer returned. It had spread to her liver and bones. She was started on a very aggressive chemotherapy regimen. Her body was unable to withstand the side-effects but the tumors kept growing. Currently she is on her third different regimen of drugs. Despite all this, she has continued to live independently and is active at work and in her community.

She had been admitted to the hospital on Sunday after noticing dark blood in her stool and vomiting bright red blood. In the emergency department she had a very low blood pressure and was admitted the intensive care unit. The GI experts were consulted and she underwent an emergent endoscopy of her esophagus and stomach. This study was done to look for a source of the bleed. However, no source was found. Her blood pressure improved and her blood counts remained stable. She was transferred to the regular medicine floor after spending three days in the intensive care unit. This is when I walked in. I described her to the rest of my colleagues the next day as "An older than stated age female with past medical history significant for widely metastatic breast cancer who presented with a presumed upper gastrointestinal bleed and hypotension (low blood pressure)." Based on just my few first words the rest of my team had already formed a picture of this person. They knew, despite anything more I would say, where I was going with this. Our team decided that she had a very poor prognosis. We declined further workup of her bleeding. We focused on making her comfortable and getting her home as soon as possible.

She was discharged from the hospital today. I was about to leave the hospital when I remembered that I had forgotten to give her one last piece of information. I walked into her room and halted. There were two people in the room sitting comfortably in chairs chatting about where they planned to go tonight. I thought I must have walked into the wrong patient's room. Both of these ladies were very well dressed and appeared to be in their 30s. They were both beautiful. Just as I was about to apologize and excuse myself out of the room, I realized that the lady on the left looked very familiar. It was Ms. M. She was dressed in her normal clothes. She was wearing makeup. She was wearing a wig that made her appear to have long brown hair. The faded, wrinkled hospital gown lay on the bed. The lady that sat before me was a completely different woman. I stammered out what I had come to say. We made small talk and then I left. As I walked away from the room I was gripped with doubt. This lady looked great. Maybe we should have kept her in the hospital and figured out why she was bleeding. We should have been more active in our search. She had told me she was active at home and at work but I hadn't really believed it until I saw her sitting there with her friend.

Did the fact that she could cover her head with a wig and make herself look young mean she had any better of a prognosis? Probably not. Did we do anything wrong? Hopefully not. But, would my workup have been different if I had seen the younger looking, well groomed, and seemingly healthier Ms. M the first day? Almost certainly. Ms. M will follow up with her primary oncologist next week. He is one of the better doctors at our hospital and knows her well. I hope I am not just passing the buck.

I can't help but feel guilty about this case even though I don't think we did anything wrong. Ms. M was presented with the options and she agreed with the team that most of the workup could be deferred or done as an outpatient. Why then do I feel that I short-shrifted her? I think I feel guilty because of my own initial feelings of pity. I presumed that his frail looking, sickly woman had little to look forward to. I couldn't have been further from the truth.