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Personal Impact and Growth Reflection - Motivation to Fight

Lisa M. Cordes, PharmD BCACP BCOP
Oncology Clinical Pharmacy Specialist
National Institutes of Health
Bethesda, MD

As oncology pharmacists, we all carry an unofficial list of memorable patients. Some leave this world before we are ready to say goodbye, and others defy the odds with no logical scientific explanation. Evidence-based guidelines and protocols provide the framework of our treatment plans, but as the great physician Sir William Osler once said, “The good physician treats the disease; the great physician treats the patient who has the disease.” Each patient has an intricate and unique web of internal and external factors that will influence his or her treatment outcome. Today, I tell the story of one of my patients, David, whose admirable fight and motivation reinforced the need to focus on the individual.

I first met David about 1.5 years ago. He was a 39-year-old teacher with a loving wife and two beautiful children who had brought his family to America for a better life. The diagnosis of metastatic urothelial carcinoma hit hard. He was decades younger than the average patient with this condition, but his disease was aggressive and his prognosis poor. Many of our patients with this disease are in their 70s with different goals and pri­orities than someone half their age. As our team discussed his prognosis and treatment options with him, I couldn’t help picturing myself in his shoes. To me, it seemed unfair that he had to face such a challenging jour­ney at his age. However, David was selfless, and his focus was on his family. He made it clear: “I want to fight, Doc.” As we would soon discover, this declaration became a recurring theme throughout his treatment. David was a spiritual man, and at 5'2" and 65 kg, I couldn’t help envisioning the epic battle of David and Goliath that we were about to fight.

Following completion of his first chemo­therapy regimen, David became hospitalized around the time of the winter holidays. As David required 6 liters of supplemental oxygen and multiple blood transfusions each week, we once again discussed the goals of therapy and encouraged hospice care. David’s response was, “I want to keep fighting, Doc.”

We had many difficult conversations with David and his wife, but this conversa­tion was one of the hardest. In fact, it was one of the most challenging of my career. It was in this conversation that we learned the full gravity of the situation. If David passed away, his family would be deported back to their home country—one without opportu­nity and freedom as we know it. Obtaining a green card for his wife was underway, but the process is slow. He was motivated to keep fighting because he refused to leave this world without first providing stability for his family. We were running out of options and time, but we were overcome with compassion and couldn’t give up. The family’s future was in our hands.

David soon began a second-line regimen. Two doses into therapy, David became extremely fatigued, and his condition was deteriorating. Once again, we heard his familiar words, “I want to keep fighting, Doc.” Through third-line therapy, his disease kept progressing, but he continued to stay motivated. With cancer patients, we often discuss treatments that extend survival and palliative care options. Patients often say their goal is to live longer to spend time with their family, and I believe this is where we need to stop and listen. Understanding the true “why” behind their decision is one of the most important variables in the equa­tion and will allow us to provide care on a deeper level. Does an elderly patient simply want to spend time fishing on the lake with his grandson? Or is it more complex with a family’s well-being at stake? David’s situation reminded me that to truly care for our patients and their families, we must understand their desires and motivations.

David’s motivation was now apparent, and following progression on third-line therapy, we heard him say again, “I want to keep fighting, Doc.” Fourth-line therapy commenced and, after months of anxiously awaiting, his wife received her green card. The clinic was full of cheers and tears. He did it; he achieved his goal.

Just this week, David’s restaging scans have showed progression. True to character, David said, “I want to keep fighting, Doc.” We will soon begin a new chemotherapy regimen, but David’s time on earth is limited. Perhaps he will be with us only for another month or two. Then again, I was proven wrong when those thoughts came to mind 8 months ago, and I hope to be proven wrong again.

Whether their goal is being comfortable or ensuring a better future for their family, our patients often thank us for helping them fulfill their last wishes. We credit our hard work, training, and knowledge, but it is patients like David who deserve much of the credit. These inspiring patients remind us that we don’t treat just the disease, but also the patient suffering from it. Although they may not always win the battle, their unique stories and motivation to fight inspire us to be better oncology pharma­cists.