I'll Meet You in Your Dreams

Abstract

In May 2012, we received a telephone call from a colleague at a regional cancer center. She asked whether we could admit a patient to our hospice—a man with relapsed, metastatic oral cancer and a life expectancy of only a few weeks. She seemed hesitant while describing the patient’s history. “This is a complicated case, from the medical as well as the psychological point of view. Dealing with the family won’t be easy. But we have to discharge him, and your hospice is the closest to his native village.” To care for patients throughout the whole course of their illness and until their eventual death, our oncology unit includes an inpatient hospice, one of the only such facilities in our region of Italy. As a result, we often receive requests for admission of patients we do not know, many with complicated medical and relational challenges. All too often, these patients tell us that they were caught off guard by being sent to a hospice, and they arrive too late for optimal clinical management. On the basis of our colleague’s description, we guessed that this patient, too, did not know his prognosis and would be unprepared to transition to a phase of palliative care only. Mr T turned out to be a wealthy and charming 45-year-old man, born and raised in Italy, who, approximately 15 years earlier, had started a business in Romania. He had been living with a Romanian woman, and the couple had a young daughter. Six months before we met him, he had undergone surgical resection and standard chemotherapy for his malignancy in Romania, but when his cancer rapidly recurred and progressed, he decided to return to Italy, hoping for more effective therapy. Three months before he was referred to our hospice, the cancer spread to the left side of his face and lymph nodes. In a desperate attempt to eradicate his disease, he underwent radical surgery to remove large parts of his face, followed by reconstructive surgery using two flaps of skin from his chest. He also required two subsequent interventions to repair surgical complications, after which his facial features were significantly altered. Despite these aggressive surgeries, the cancer quickly recurred again and progressed rapidly, eroding into the bones in the skull. He received palliative radiotherapy, but cure was no longer possible. And so Mr T was sent to our hospice. He was able to see only with one eye and could do that only by lifting his ptotic eyelid with his fingers. Skin and lymph node metastases were visible in his neck and chest. He required frequent aspiration of pus-like secretions from his tracheostomy and was fed through a gastrostomy. He could still walk for a few steps with some help, and his pain was adequately controlled by a continuous infusion of morphine. No longer able to speak, he was forced to communicate in writing, but what he wrote made it clear that his mental status was still normal. As we had anticipated, despite all that he had been through, the patient seemed unaware of the rapid and irreversible worsening of his clinical condition. He informed us that he had not been told by the referring hospital that he was going to die, but rather that the goal of this admission was to help him recover from damage caused by the palliative radiotherapy. It was painful to watch Mr T ask about all the details of his care plan with the idea that he could still be cured. More than anything, he wanted to get well enough to go back home to his 8-year-old daughter in Romania, even though he realized that this was outside his grasp at the time he arrived. Mr T was an ambitious and intelligent man, with a good sense of humor. When we asked him to suggest how we could reduce the lengthy, intrusive visits of an overzealous family member, for instance, he replied by making a hand gesture that mimed shooting her with a pistol. Despite his physical limitations, he was charming toward the hospice personnel, paying special attention to young female nurses. Of course his face was not even close to what used to be—but he would often show an old picture of himself before the disease, as a reminder of his past as a Latin lover. Walking by his room, we would sometimes catch him sitting on the edge his bed, with his elbow leaning on the bedside table and his fingers lifting his paralyzed eyelid, staring at his destroyed face in a mirror. We wondered how he could possibly cope with such a devastating change of his appearance. JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 31 NUMBER 4 FEBRUARY 1 2013