JOURNAL OF PALLIATIVE MEDICINEVolume 12, Number 1, 2009© Mary Ann Liebert, Inc.DOI: 10.1089/jpm.2009.9688

My Friend, My Patient

Kavitha Ramchandran, M.D.

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THE PHONE CALL came at 6:00 PM. I was on the shuttle homeand feeling the first tingle of excitement. My flight to

Santa Fe was 12 hours away. It was a well-deserved breakafter 6 months of mind widening, but exhausting work as anintern.

“Jennifer, can you come to the hospital? It’s about Susan*.”My mood dampened as my mind flashed on my friendshipwith Susan. Susan was a 35-year-old teacher who loved pol-itics, a good cup of tea, and serial episodes of Sex and theCity. We met 3 years before when I was a medical studentand she was a patient in my longitudinal oncology clinic.

My first memory was of her sleeping. An eloquent med-ical description might have read, “pale, young woman, frailappearing in NAD.” Thankfully, I was not well versed inmed-speak at the time. My only thought was, “She lookstired, and I don’t want to wake her.” As I struggled with thisdecision, she yawned loudly, slowly opened her eyes andlooked directly at me with a smile. “Hi! You must be themedical student Dr. Gordon was telling me about. Come sitwith me.” I sat down and we talked about mundane things;the weather, her recent move to San Francisco, her newhouse, and her husband Tony. Coincidentally we had got-ten married in the same year and bought homes in the sameneighborhood. At the end of our conversation I knew verylittle about her illness, but I knew that I liked her very much.

I had an interesting dilemma. I met Susan in a medical ca-pacity but I had an overwhelming desire to pursue a friend-ship with her. There were certain boundaries that would dic-tate that I maintain a professional relationship. However Iwas still so “green” that these boundaries felt fuzzy. In theend, I threw caution to the winds and followed my gut.

Over the next 3 years our friendship grew. We took longwalks in Golden Gate Park, baked together, and chatted overbig jugs of tea. Occasionally I accompanied her to doctor’sappointments and asked responsible, mildly medical ques-tions. She reciprocated with books on everything from po-etry to gardening with her well annotated thoughts. Al-though I had access, I never looked at her chart, or at anyimaging reports. She never asked me to either. Our friend-ship had taken precedence over our medical relationship.

In our last year of friendship I knew her illness was pro-gressing. Susan had developed refractory ascites that re-quired serial taps. She was also quite fatigued and walks to-gether became less frequent. We spent more time watching

our favorite serials. I did more of the cooking and baking. Iwas aware that these were bad signs, however, I was not di-gesting them. She was young, and I had faith that modernmedicine would pull her through.

The phone call was a jolt to reality. “Yes, of course,” I toldTony. “Tell me what is happening?” Tony started sobbing.He told me Susan had been vomiting blood since morning.She had been admitted to the intensive care unit and theywere unable to stop the bleeding.

I got off the shuttle at the next stop, which was my hos-pital. I took the familiar elevators to the ninth floor; the sameICU where I had learned about ventilator settings and pres-sors. I was greeted by the ICU nurses and one or two of mycoresidents. I nodded and smiled in a mild daze and mademy way to Susan’s bed.

I looked in, expecting to see something horrific; a massof blood, tubes, monitors, a crash cart open and ready togo. Instead, I saw my friend. She smiled and asked me tocome in. For a moment it was as if I were walking into herbedroom. I gave her a hug and sat down. Within a fewminutes, Dr. Gordon, her oncologist came in. He gave Su-san his signature bear hug and sat down. He told us franklythat the tumor had eroded through Susan’s gastrointesti-nal lining such that she would continue to bleed. Therewas no intervention. The ICU could temporarily supporther with transfusions, but this could not continue indefi-nitely.

She smiled, and said, “No of course not, that wouldn’t befair to others, would it?” Tears were running fast and freeon my face, but her eyes were dry for that moment.

I was processing this influx of information when her res-ident walked up to me. They wanted to transfer Susan to apalliative care bed. However, they did not think it would befeasible because of the active bleed. Additionally, Susan hadmade a request to be transfused until she had said her good-byes. The staff was not sure if they would be able to honorher request in a palliative care bed.

Although I had made a conscious decision to not play amedical role in Susan’s life; at this moment I knew that as aphysician I could do more for her than as a friend. I told herresident that I would be her personal physician upon trans-fer to a palliative care bed. I would manage her transfusions,her pain medications, and any other supportive issues thatarose. Honestly, I was not sure how I was going to do this.

Oncology/Palliative Care Fellow, Robert H. Lurie Cancer Center, Northwestern University, Evanston, Illinois.*All names have been changed to protect confidentiality.

Personal Reflection

I had minimal training in this field. I was again followinggut instinct over reason.

Under these auspices they arranged for Susan’s transfer.Dr. Carson, the palliative care attending, found me in thehall as they were processing her move. She gave me her cellphone number and home phone number and told me to callher every 2 hours throughout the night with any issues thatarose. Like a brave young physician, I told her I would callif I needed to, but would try to refrain. She stopped me andsmiled. “No,” she reemphasized, “I want you to call meevery 2 hours, even if everything is going fine.” At that mo-ment, I knew everything was going to be okay. I was not do-ing this alone.

The next 12 hours were uneventful. I called every 2 hoursand Dr. Carson and I chatted. The night was uneventful. Wegathered family and friends, ordered food, and set up campin her room. I had moved into coordinating mode; dealingwith foot traffic, medication orders, family requests (i.e.,Where’s the bathroom?). Doing these small things allowedme to avoid the big picture; that my friend was dying. Thatevening Susan told me she wanted enchiladas from her fa-vorite restaurant. The day had been so quiet that I felt com-fortable stepping out to make the short walk to get her food.

As I was returning my phone rang, “Jennifer, somethinghorrible has happened.” I hung up the phone and raced upto Susan’s room. When I came in Susan was moaning in pain.She was tugging at her sheets, at her clothes and graspingat her swollen belly. She was unable to track or answer ques-tions. This had come on acutely. I ordered the nurse to comein with a shot of morphine. It had no effect. I called Dr. Car-son and we doubled her dose, still with no success. We con-tinued over the next 2 hours to escalate her doses of mor-phine. By this time it was night and I was calling Dr. Carsonevery hour for direction. Susan continued to toss, turn, andgrimace and with each passing moment my helplessness

grew. I wanted to give her one final gift; to remove her painand suffering, and I felt wholly inept to do so. As dawn ap-proached Susan quieted, and she appeared to be more peace-ful. She was no longer writhing, and her breathing had takenon a more comfortable pattern.

That morning Susan died. Her last few hours were peace-ful and her friends and family were by her side. I did nothave time for tears. I was coordinating the signing of thedeath certificate, calling the medical examiner, and talkingto the nurses.

I had spun quickly into my physician role. It felt com-fortable and impersonal. As the last individuals left, thenurse walked out of the room and told me there was still apersonal belonging left behind. I walked back in, and ini-tially did not see anything. The nurse pointed to Susan’sblanket, an Indian block print cotton sheet that I had givenher.

I told the nurse to leave the blanket with her. As I turnedaway, I started to cry.

Acknowledgments

Special thanks to Dr. Joshua Hauser and Dr. Jamie VonRoenn for their editorial support.

Address reprint requests to:Kavitha Ramchandran, M.D.

Oncology/Palliative Care FellowRobert H. Lurie Cancer Center

Northwestern University400 E. South Water Street

Chicago, IL 60601

E-mail: kavitha.ramchandran@gmail.com

PERSONAL REFLECTION96