The family meeting

They slowly enter the conference room and gather around the large wooden table. His parents, the two sisters, the two brothers-in-law, several aunts and uncles, many nieces and nephews, some with their boyfriends and girlfriends. Everyone is here except for his two daughters aged nine and seven. The girls already visited their father yesterday. The younger one fearfully refused to enter the room and waited outside the partially closed door. The older girl bravely went in and saw her father drifting in and out of consciousness, unable to talk through the non-rebreather face mask, both his arms hooked up with multiple intravenous lines, his abdomen and legs swollen. His mother later told me that the two girls went home and cried all night. Their grandparents decided not to bring them in for this family meeting today.

There are barely enough chairs for everyone. I’m sitting next to the attending oncologist, across the table from the parents. The windows are closed, and I wish I had opened them before the meeting. It feels oppressively warm in here, the air not circulating well. Outside, through the partially closed shades I can see the brilliant spring flowers swaying joyfully under the bright sun. For a moment I wish that I were not here, that I were walking my two-year-old daughter to her favorite playground in our neighborhood park, that I were having a dinner date with my wife in a sushi restaurant. For a moment I wish that I were not a cancer doctor.

Once everyone takes a seat, I introduce myself and my attending, the nurse, the palliative care team. Throughout his long hospital stay countless doctors have taken care of him. Most of us only stay for one month before rotating to another service. He has been here since the stem cell transplant and has collected a stack of physicians’ photo cards on his bedside table. But when days turned into weeks, and weeks turned into months, our faces must have blended together. The white coats of the physicians, the brown and green scrubs of the nurses, the black uniform of the food service staff. I wonder what he has seen in the past few days, if he sees anything at all. Has he recognized any of our faces?

I ask the family to introduce themselves. They go around the table, each calmly stating his name and relationship to the patient. Once the introduction is done, I state the agenda of the meeting–updating them on his condition, sharing our latest recommendations, and answering their questions. I briefly summarize what he has been through, the diagnosis of acute leukemia last year, the chemotherapy treatment, the stem cell transplantation, and the current post-transplant complications with graft-versus-host disease, infections, and multi-organ failure. I try to avoid medical jargon, sticking to more easily understandable terms. “Graft versus host.” Who invented this terrible phrase? So impersonal, so clinical.

I share with them the details of his current clinical deterioration. I look around the room. They all know what is coming next. “Unfortunately he is dying,” I conclude. And many of them start crying. The father, who has always been the most stoic of them all, wipes his eyes. We pass them the Kleenex.

During my first year of medical school, we learned how to give bad news in a course simply titled “Patient-Doctor”. We took turns playing physician and patient, practicing how to place ourselves in front of the patient, learning how to use certain words while avoiding others. We learned when to be brief, when to be direct, when to let silence rule the room. Then we entered residency and learned to give bad news and forgot everything we learned. We learned by fumbling through these family meetings. Some of us never have to run such a meeting. Some of us–the oncologists and the critical care specialists–have more practice than we have ever wanted.

A few days ago I told him that he was critically ill and asked for his wish regarding end-of-life care and resuscitating effort. What were his goals? What were his values? How would we best respect those? Would he want to be transferred to the ICU? Would he want to be intubated, having a breathing tube down his throat, hooked up to a ventilator, sedated? Would he want to have CPR performed? He looked away, and we both remained silent for a full minute. Then he said, “What am I supposed to say? I have two kids at home.” I could not respond and just took his edematous hand in mine.

Now looking at the teary faces in front of me, I thinks of his two kids at home. They are probably at school actually. And I ask about them. “We will take care of the girls,” many of them say. They ask more questions about the disease. His sister–the one who donated her cells to him–looks up, her eyes red, “Graft-versus-host disease. Did… did I kill him?” And she again bursts into tears. No, of course not, my attending steps in, explaining what little we know about the mystery of the human body, of life.

I start talking about our recommendations, about trying to preserve his dignity, about shifting the focus to comfort care. The family express agreement. In the end, the father, who has remained quiet throughout the whole meeting, speaks up to thank us for our work. “I know you all did your best. Thank you.” His voice quivers.

We leave the room to give them time for themselves, to grieve. “Good job at the meeting,” my attending commends on our walk back to the work room. I simply nod. All my years of training just for this–giving bad news well?

Later that night, driving home on the dark highway cutting through the hills behind Stanford, impatient to be home to see my two kids, I think of him again. And of his young daughters. What are they doing at this hour? What will their lives be like? Did I kill him? Why couldn’t he be saved? No forty-two-year-old man should die. No father of young children should die like this. I must have screwed up somehow somewhere. Suddenly I feel an overwhelming wave of fatigue hitting me hard. I struggle to stay in my lane as my eyes become blurry with tears.

(Many details have been changed to protect patient’s privacy.)