Bony Mets

At County Hospital in mid-February at palliative care rounds, we discussed how patients often confuse metastases to the bone (“bony mets”) with primary bone cancer and think they’re getting the wrong treatment because it’s not what the Internet says should be done for bone cancer.

We had four family meetings scheduled that day. Before one of them, the palliative care fellow at the time, George, mentioned that hospice is both a service and a philosophy of care. He reassured the family of one patient that hospice is attached to the patient, not to a particular location. Wherever the patient ends up, she can get hospice care. Before another meeting later, he told a couple of other physicians that there are generally two things to be decided: what type of care will be provided, and where it will occur. You can uncouple these and tackle one or the other in a given meeting.

When we arrived for a meeting in the afternoon and counted how many chairs were needed, the patient’s family said, “We don’t need chairs,” and that’s how we ended up standing for 90 minutes around a sleeping patient’s bed. A non-palliative care physician started this meeting by saying, “So, what are your goals of care?” He was obviously trying to do the right thing, but I’ve never heard a palliative care provider say anything like that. Quite often, they start by saying something like, “Can you tell us what you understand about your mother’s condition?” Then they might ask if any changes have been observed recently. They ask permission before giving bad news: “We have received your mother’s test results. Do you want to hear about the findings?”

This particular family had gone around and around in prior meetings, and this conversation also went in circles for a while, but eventually it was understood by all in the room that there was nothing that could be done to restore the patient’s health, and also that it would be impossible for her family to care for her at home. We discussed a certain place she might go, and, at 75 minutes in, it was sounding like this was an option the family would be all right with. During the final 15 minutes, one family member after the other thanked us profusely, which was very sweet, though I must say my feet were really killing me by then.

Helen told me in the afternoon that they were going to meet with George to offer him a job at County Hospital after his fellowship ends. I was delighted for him. He is a really sweet person and a wonderful communicator, a master of reflective listening. It occurred to me that another of the palliative care attendings at County Hospital was also a fellow when I first met him, and I thought he was totally fantastic, too.

Around then, I got together with fellow students from my school in Santa Fe; we do this every couple of months. Carol-Joy came to town and we had breakfast at Santaneca and then spent the afternoon playing cards, and Charlie and I also went to Santaneca.