In the first few weeks of the COVID pandemic, I lost a patient. Not to coronavirus, but to colon cancer. I received the alert in my electronic health record: “Post Mortem.” His kind oncologist had already notified me about his death via email, so I was not surprised with the alert, but I still felt the sadness and despair that comes with this kind of loss. Later that afternoon, I shuffled through my paper inbox at clinic, finding a mountain of faxes about his last days in and out of the hospital, battling a cancer that choked off his gut. My breathing quickened and I felt torn between truly feeling my emotions or pushing them to the side in service to the pandemic, which was already forcing providers to shoulder deep sadness and despair. I deliberately took a deep breath and kept going.
I called his family to express my condolences. The electronic health record is not set up for this kind of work, although it is some of the most important work we do as family physicians. The phone rang as I scrolled through the fields of the telephone encounter template struggling to choose a “reason for call” as the electronic health record demanded. I tried “sympathy” but that only matched to “symptom management.” I found another one for “Transition of Care” which seemed appropriate in a celestial sense. I settled on “Primary Care Outreach,” but the ringing stopped and the call went to voicemail. I left a message. Some part of me was relieved.
I will miss this patient, perhaps more than I have missed others, because it didn’t have to be this way. He died of the one of the most preventable cancers, presenting with a bowel obstruction that turned out to be a rectal adenocarcinoma with metastasis to his liver. At the time of his diagnosis I reviewed his health maintenance tab, the part of the electronic health record that is supposed to help us avoid these kinds of outcomes by reminding us of preventive care. For each of the preceding 5 years, “declines screening” appeared in the colon cancer section. When he came to see me soon after he started chemotherapy, I asked if there was anything I could have done differently to change his mind about screening, anything I could have said. No, he replied, I am stubborn and you did the best you could.
It still gnaws at me: maybe I could have done better with motivational interviewing or checked his hematocrit more often to uncover anemia and have a reason to send him for colonoscopy. Toward the end, when it seemed like his third kind of chemotherapy might work I asked him to come back in 2 months.
“How about next month, doctor?” he asked.
“Yes, of course,” I replied. I think he knew.
In these shifting days of a pandemic, filled with telemedicine, surge redeployment to a respiratory care clinic, children at home who long for peace and comfort, I try when I can to hold a space for him. Grieving is complicated in these difficult times. He was, like all patients, a mix of experiences. He quit smoking after I diagnosed him with COPD. There was that time he called me “Honey,” telling me that he would trust whatever breathing medication I selected for him. He was the kind of caretaker for his wife that every person would dream about. He trusted me. I feel like I failed him and said as much. He told me I was wrong.
During these dark hours, it’s the simple things I latch onto: the sounds of birds harkening springtime, the sunrise that comes earlier each morning, and the way my children smell after a bath. And once my initial wave of sadness had passed, it is this man, whose light has gone out, whom I cared for in the simple yet deep ways we care for patients in primary care, whom I loved in that way doctors love their patients. I cling to memories of my time with him, those brief moments we spent together in the 15-minute intervals of a return visit. I mourn for him, knowing there will never be a “reason for call” for the things we really need. I will not find one labeled “Regret.” I will not find one labeled “Sadness.” I will not find one labeled “Despair.” I will not find one labeled “Failure.”
Even during normal times, there will never be a “reason for call” for “Loss.”
