Another Infusion of Hope
Authors: Francesca Giorgi, Romeo Bascioni
Journal: Journal of Clinical Oncology (2009)

Hope is a strange invention – A Patent of the Heart – In unremitting action Yet never wearing out – —Emily Dickinson It was an ordinary Monday morning at the outpatient oncology clinic. As usual, it was a busy day; the waiting room was crowded with patients lining up for examinations, laboratory tests, and chemotherapy sessions. Telephone calls about the myriad of problems that had occurred over the weekend, requiring unscheduled visits to the clinic, never seemed to end. Late in the morning, a colleague from gynecology called me. “My sister is rapidly getting worse. Could you please come with me to see her this afternoon at her house?” I was tired, but I could not say no. My colleague’s sister, Mrs G, was a woman 45 years of age with metastatic adenocarcinoma of the lung, which had been diagnosed 8 months ago. She had been treated at our clinic with cisplatin and gemcitabine, then erlotinib, and then pemetrexed. None of these treatments were effective. Pemetrexed was stopped because of her deteriorating clinical condition. Mrs G was a bright, educated, quiet woman who left all decisions concerning her clinical care to her husband and sister, never asking direct questions about her disease. The most important thing for her was knowing that if one treatment failed, we would be able to offer her another treatment. I knew her family well, including her husband—an influential and wealthy man who had always taken care of her and her son, who was 18 years of age, with loving affection. Their social status had allowed them to consult with almost every Italian lung cancer expert, perhaps searching for someone who would deny, or at least mitigate, Mrs G’s dismal prognosis. She returned from each consultation more hopeful. Every mention of a promising experimental therapy was considered an actual possibility of cure, and every attempt to bring her back to grim reality was stopped by her husband and sister. “Please, let her still have hope. She believes that her disease can be controlled for a long time, even though she realizes she won’t be able to recover.” After an emotionally charged discussion with the family, we reached an agreement. As long as she did not ask me specific questions, I would not give her additional details about her prognosis. When she came to the clinic for her last cycle of pemetrexed, she walked slowly, leaning on her husband’s arm. I asked her how she felt, probing for new symptoms. She did not ask any questions about her clinical situation, and attributed her severe fatigue to previous treatments. The family members reinforced her opinion by reassuring her about the efficacy of pemetrexed. When I mentioned the possibility of disease progression, I received no reply. In the next few days, her condition deteriorated rapidly, and she became unable to return to the hospital. Her sister told me that she was now almost completely bedridden. Although pain and dyspnea were under reasonable control, her main concern was her inability to go to the hospital for more chemotherapy. I arrived at her house late in the afternoon. Her husband and son were waiting at the doorstep, looking distressed, with tearful eyes. I went to her room on the first floor. She was lying in bed, receiving an intravenous infusion. She welcomed me with a big smile and said, “Doctor, do you believe this chemotherapy will work?” At first I thought she was confused, but then her sister whispered to me, “It’s only folic acid in normal saline, but she believes it’s chemotherapy.” Not really knowing what to do, and almost against my will, I could not help saying, “I hope so.” Two days later, her sister informed me that she had died quietly, in a drowsy state. “She was peaceful.”