The forgotten spouse.

DOI: 10.1200/JCO.2009.22.1069 It was early in my training as a radiation oncology resident when I met Mr and Mrs C, who changed the way I approach oncology patients and their families. I arrived in Boston, MA, eager to start a new journey, one that would lead me toward competence in the care and management of patients with cancer. As I was studying the principles of clinical oncology, radiobiology, and medical physics, a meaningful encounter with two people helped me to appreciate my practical limitations and role as a physician. We had been swamped all day with consults in the thoracic oncology clinic and still had one patient left to see. I quickly reviewed my notes—a 69-yearold female with multiple comorbidities and a 50– pack-year smoking history with recently diagnosed stage IIIB non–small-cell lung cancer. Waiting to see me was a lovely couple who had been married for almost 50 years. Although Mrs C seemed chronically ill and was on supplemental oxygen, she carried herself with grace and exuded softness second only to my great-grandmother. Mr C was thin, gray-haired, and wore glasses. He was attentive and raised appropriate questions about his wife’s disease. They had two grown children and six grandchildren, of whom they spoke with adoration. It did not take long for me to realize that the Cs were more than a couple—they were soul mates. Well into their old age, they continued to indulge in one another and were beaming with companionship. In collaboration with the medical oncology team, we recommended combined-modality therapy consisting of radiation and concurrent chemotherapy. Mrs C had an intrinsic calm about her illness, and I felt she had accepted her fate. She was not keen on any treatment that would cause her to bear significant adverse effects. Confronted with the possibility of losing his wife, Mr C went so far as also requesting surgery. It is debatable whether Mrs C was fit enough to receive any aggressive treatment given her performance status; nevertheless, this regimen, if completed, was our best hope for a positive outcome. Mrs C had a difficult time tolerating her treatments. Her appetite declined and she lost weight. She also developed headaches, respiratory problems, nausea, fatigue, esophagitis, and myelosuppression, necessitating a brain magnetic resonance imaging, chestcomputedtomography,andadditionalwork-up. I made it a point to meet with the Cs every day, and with time, became emotionally connected. As the days progressed, I observed tension developing between the couple. For instance, Mrs C started refusing to eat because she had no appetite and periodic bouts of nausea. Mr C valued the intimacy from meals together at the dinner table and began missing this daily ritual. Their individual needs, although generally in sync, were now at odds with each other. I encouraged Mrs C to opt for smaller, more frequent meals, and we even tried caloric supplements and appetite stimulants, but to no avail. Despite her worsening condition, we pushed her to continue. Ever the devoted spouse, she persevered. Mr C would convey enthusiasm if his wife maintained her weight or was able to keep food down for any given day. These became his benchmarks for success. To him it seemed that if she could just get through her treatments, then perhaps the disease would go away for good. It is unclear if Mr C’s attitude was shaped from any of my words, but I regrettably did not take any action at the time to help him better cope with these feelings. When I look back, Mr C’s internal distress was only peripherally explored during our frequent encounters. Instead, I was more involved in helping Mrs C to finish therapy. As time went on and she stopped meeting these benchmarks, I could sense Mr C’s disappointment. While she was suffering the physical aches of her rigorous treatment course, I believe he was experiencing pain at a deeper, emotional level. It was disheartening to witness such joint suffering, and I often felt powerless. Given Mrs C’s continued physical decline, she took a short break from chemotherapy and then from radiation. Neither of these seemed to help and she started to lose morale. When she no longer had the will to get out of bed to commute in for her treatments, the Cs opted for supportive care. A few days later as we were arranging for transition to hospice, our nurse informed me that Mrs C had passed away at home in her sleep. Although I felt somewhat relieved that her suffering had finally JOURNAL OF CLINICAL ONCOLOGY T H E A R T O F O N C O L O G Y VOLUME 27 NUMBER 25 SEPTEMBER 1 2009