The Black Dress

DOI: 10.1200/JCO.2011.38.1715 Mrs. F was a middle-aged woman from a nonWestern culture who had lived in a European city for many years and was fluent in English. Accompanied by her eldest son and daughter, she came to see me for a consultation; she was seeking adjuvant treatment for early-stage cancer. We discussed her diagnosis and good prognosis, as well as the risk of relapse and potential adverse effects of treatment. Although the specific chemotherapy regimen I recommended was available worldwide, Mrs. F wished to receive her care here in the United States, where she remained for 6 months of outpatient treatment. At almost every visit, Mrs. F and I enjoyed lively and intense conversations about her life, her family, her cultural and religious background, and her experiences living in different countries. After she completed her adjuvant chemotherapy, she returned to the United States at regular intervals for follow-up visits, and we also kept in touch by phone. Two years after she had completed treatment, Mrs. F brought scans to a follow-up appointment. The scans showed that she had metastatic disease that involved visceral organs. At first, Mrs. F and I were alone in my office; her daughters sat outside. When I began to gently explain the meaning of the results, she interrupted me, saying that she understood that her situation had worsened but did not wish to know the details. She stressed that in her culture, it was best not to know too much. She went on to say that she trusted me and wanted me to give all of the information to her children, who would accompany her at each visit. Her family decided that staying in the United States would give her the best chance for longer-term survival. Unfortunately, Mrs. F’s cancer did not respond to any treatment. At every indication of additional progression, I asked Mrs. F if she wished to know more about her condition, but she always refused to hear additional details. She grew weaker from the disease and the consequences of treatment and eventually was hospitalized with an infectious complication. On the hospital ward, I discussed with the medical and nursing staff Mrs. F’s request not to be directly informed of her cancer status. We talked about how difficult it is to balance appreciation of and respect for our patients’ different cultures with adherence to Western values of patient selfdetermination and participation in care. We were aware that great effort was involved in shielding Mrs. F, especially while she was an inpatient, from receiving bad news directly from hospital staff outside of our unit. Yet, we all concurred that it was appropriate as a team to comply with her wishes and continue to give information to her relatives. When I visited Mrs. F at night after my clinic hours, I would often find her alone. She never asked me about her condition; instead, she told me stories about her life. Suddenly, one Friday afternoon, the resident who was caring for Mrs. F called to tell me that Mrs. F’s family had arranged for an outside consultation about her cancer, and they needed a pass for her to travel by ambulance to a surgeon’s office the following day. I told the resident that I was in my outpatient clinic but would come up to the ward after clinic hours. The resident was surprised to learn that the family had not discussed the consultation with me personally, but I explained that in their culture they might have felt embarrassed about seeking a second opinion. Still, I said, there was no surgical option for her cancer, and even if the consultant agreed not to tell Mrs. F the whole truth, something might be said to her about her condition that would prove devastating for her. Because I had been her treating oncologist for several years, I felt that I had to prepare Mrs. F somehow for this consultation. My clinic ended late. I had been invited to a formal event with a black-tie dress code at an embassy that evening. I decided to skip the ceremony, and at around 8 PM I went to Mrs. F’s room. Unexpectedly, I found her alone, lying in bed. She appeared short of breath and seemed to be very concerned about getting permission to leave the hospital for a few hours the next morning. She asked me to sign the pass form immediately. We looked at each other in silence for a few moments that felt like hours. I told her I would sign the form, but that I wished to provide more information about her cancer before she met the surgeon. I asked her if she wanted a relative to be present for our discussion; if so, I promised her, I would wait for one of them to arrive. She said that she preferred to be alone with me. JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 29 NUMBER 31 NOVEMBER 1 2011