Before I began to think about what awaits my older patients—people very much like Lou Sanders and the others—I’d never ventured beyond my surgical office to follow them into their lives.
But once I’d seen the transformation of elder care under way, I was struck by the simple insight on which it rested, and by its profound implications for medicine, including what happens in my own office.
And the insight was that as people’s capacities wane, whether through age or ill health, making their lives better often requires curbing our purely medical imperatives—resisting the urge to fiddle and fix and control.
It was not hard to see how important this idea could be for the patients I encountered in my daily practice—people facing mortal circumstances at every phase of life. But it posed a difficult question: When should we try to fix and when should we not?
Sara Thomas Monopoli was just thirty-four and pregnant with her first child when the doctors at my hospital learned that she was going to die. It started with a cough and a pain in her back. Then a chest X-ray showed that her left lung had collapsed and her chest was filled with fluid.
A sample of the fluid was drawn off with a long needle and sent for testing. Instead of an infection, as everyone had expected, it was lung cancer, and it had already spread to the lining of her chest.
Her pregnancy was thirty-nine weeks along, and the obstetrician who had ordered the test broke the news to her as she sat with her husband and her parents.
The obstetrician didn’t get into the prognosis—she would bring in an oncologist for that—but Sara was stunned. Her mother, who had lost her best friend to lung cancer, began crying.
The doctors wanted to start treatment right away, and that meant inducing labor to get the baby out. For the moment, though, Sara and her husband, Rich, sat by themselves on a quiet terrace off the labor floor.
It was a warm Monday in June. She took Rich’s hands, and they tried to absorb what they had heard. She had never smoked or lived with anyone who had. She exercised. She ate well.
The diagnosis was bewildering. “This is going to be okay,” Rich told her. “We’re going to work through this. It’s going to be hard, yes. But we’ll figure it out. We can find the right treatment.” For the moment, however, they had a baby to think about.
“So Sara and I looked at each other,” Rich recalled, “and we said, ‘We don’t have cancer on Tuesday. It’s a cancer-free day. We’re having a baby. It’s exciting. And we’re going to enjoy our baby.’ ” On Tuesday, at 8:55 p.m., Vivian Monopoli, seven pounds nine ounces, was born. She had wavy brown hair, like her mom, and she was in perfect health.
The next day, Sara underwent blood tests and body scans. Paul Marcoux, an oncologist, met with her and her family to discuss the findings. He explained that she had a non-small cell lung cancer that had started in her left lung. Nothing she had done had brought the disease on.
More than 15 percent of lung cancers—more than people realize—occur in nonsmokers. Hers was advanced, having metastasized to multiple lymph nodes in her chest and its lining.
The cancer was inoperable. But there were chemotherapy options, notably a drug called erlotinib, which targets a gene mutation commonly found in lung cancers of female nonsmokers; 85 percent of them respond to the drug, and, as Marcoux said, “some of these responses can be long-term.
Words like “respond” and “long-term” provide a reassuring gloss on a dire reality. There is no cure for lung cancer at this stage. Even with chemotherapy, the median survival is about a year.
But it seemed harsh and pointless for him to confront Sara and Rich with that fact now. Vivian was in a bassinet by the bed. They were working hard to be optimistic.
As Sara and Rich later told the social worker who was sent to see them, they did not want to focus on survival statistics. They wanted to focus on “aggressively managing” this diagnosis.
So Sara started on the erlotinib, which produced an itchy, acne-like facial rash and numbing tiredness. She also underwent a needle drainage of the fluid around her lung, but the fluid kept coming back and the painful procedure had to be repeated again and again.
So a thoracic surgeon was called in to place a small permanent tube in her chest, which she could drain by turning a stopcock whenever fluid accumulated and interfered with her breathing.
Three weeks after her childbirth, she was readmitted to the hospital with severe shortness of breath from a pulmonary embolism—a blood clot in an artery to the lungs, which is dangerous but not uncommon in cancer patients. She was started on a blood thinner.
Then test results showed that her tumor cells did not have the mutation that erlotinib targets. When Marcoux told Sara that the drug wasn’t going to work, she had an almost violent physical reaction to the news, bolting to the bathroom in mid-discussion with a sudden bout of diarrhea.
Excerpt From: Atul Gawande. “Being Mortal.”