You Have Seen Her Before
Authors: Nikhil Barot
Journal: Journal of Clinical Oncology (2016)

You have seen her before, a gray-haired woman late in years, her skin deeply wrinkled, her gait unreliable at best, body thin, air occasionally struggling to evacuate fromher puffed-up lungs. Her body has been ravaged by smoking, and age has left its debris, yet her will seems intact. She did not want to come to your hospital, believing that her abdominal pain could be managed with more Norco at home, but her youngest daughter insisted. The film of her abdomen showed constipation, and she was relieved to hear this, yet her heart raced on, inexplicably. You perform a scan of the thorax to look for an occult thrombus, but instead of a clot you find a mass. You study the scan, scroll through first axially, then sagittally, but it never strikes you that these various views cannot reveal other truths. The mass is large and central, recumbent in the right upper lobe. Such an incidental thing, you think, marveling at the happenstance of it all. You can get this, you tell yourself, so you and your fellow reach for the tools of your trade and explain what you can do for her. “Just let me home to die,” she says. “I want to go home.” She’s not lucid, you think. You’ve heard she’s had a stroke, recorded in a past chart. “But ma’am,” you insist, “we suspect you have lung cancer and we need to do a procedure to be certain. Once we know it’s cancer, we’ll talk about treatment.” “I just want to die,” she responds. Youturn toher son-in-lawandbegin toreason with him. It’s not very long before she acquiesces to your combined persuasion. You describe the menu of terrible things that can happen during the procedure, as if it’s something you’re certain she can understand. You reverse her do-notresuscitate order for the duration of the procedure. You make her comfortable and enter her mouth with your scope, past the epiglottis and the cords, past the tracheal rings that guide you deeper into her lungs. There it is, the vagrant, slumbering in the right upper lobe, a smooth gray mass with bright vessels coursing along its surface. You’re afraid it will bleed, so you brush it first. No blood. You take your first bite. No blood. You take several more and are astounded by how little it bleeds. How lucky, you say. A few hours later, the patient is sitting in her bed. You come to her when you hear she is feeling short of breath. She’s wheezing, so you administer the proper treatments and order another film. She worsens. You see that she is struggling for air. You consider the do-not-resuscitate order that you reversed earlier. It would have reverted by now, hours after the scope was removed. You must reverse it again, needing to fix what ails her now, but she’s too weak to approve. You try to reach her daughter, but to no avail. You think that she never wanted any of this, not the tumor, not the scope, not the complication. You intubate her, wondering if it’s the right thing to do. You reach for the scope again and enter her airways. You suction out some large clots of blood. You stabilize her and leave her in the care of your colleague. The next morning, your colleague tells you of the patient’s sleepless night. She bled again, was scoped yet again, but this time the bleeding had no easy fix. One lung collapsed, then the other. Her skin erupted with unsightly pockets of air. You arrive at her bedside and see a miserable version of the woman you had met just the day before. Chest tubes drain air incessantly from each lung. Catheters and tubes violate every orifice. She’s developed oliguria, and her blood pressure is low. And there, clinging to her right hand, is the daughter you had tried to reach yesterday. “She didn’t want any of this,” she weeps. Your own hand finds her shoulder, for you’ve nothing to say. Her family gathers, and you sit with them in a room not far from the one in which she lies moribund. You say a few words; you let them speak, and you listen. You listen to them as you hadn’t listened to her. Your zeal is gone. Afterward, you walk to her bedside and write the orders to extubate. Life leaves her, and you come home. And you sit and think and think.