Mr. D. is one of those guys who is just nice. He’s far from gregarious, but everyone who meets him likes him. He’s quiet, reserved, and hates to complain. He’s had his share of medical problems over the last 80 years—emphysema, lymphoma, prostate cancer—all of which he’s treated as inconveniences.

When he came into my office with his wife, he looked miserable. His back was hurting so badly that he couldn’t get comfortable. It had been like that for two weeks, but he didn’t want to bother me about it.

I asked him the usual questions—any fevers, weakness, incontinence—all negative. By history and exam, he appeared to have a usual case of low back pain, but with his medical history, you can never be too careful. He had been on immune-modifying drugs for rheumatoid arthritis, so infection was a consideration, as was cancer. I did some plain X-rays in the office which were unremarkable, and he had an appointment with a spine surgeon in a few days, so I sent him home with some analgesics and instructions to call me if things got worse.

Things got worse.

A few days later he couldn’t get up. He wasn’t weak, but the pain was so excruciating that he was in tears. His wife called an ambulance, and I admitted him to the hospital.

An MRI revealed what an X-ray did not—masses in his spine, and lots of them. There were a few possibilities. He had a history of prostate cancer, but this had been under control. His lymphoma was “cured” years ago. He had been a big smoker, but his chest X-ray was fine.

I ordered a biopsy, which was done fairly quickly, and continued to treat his pain with escalating doses of narcotics.

The biopsy came back 4 days later—lymphoma. Not good. We sat and chatted, and he was in his usual mode of, “OK, then, let’s get on with it.”

Radiation oncology and medical oncology came by, and decided that chemotherapy was his best option. Chemotherapy has advanced tremendously over the last decade, not just in its ability to treat disease, but also in our ability to minimize the unpleasant symptoms of treatment. Unfortunately, Mr. D. didn’t “read that book”. He was miserable. First came the mouth pain. Then the pain with swallowing. Then the nausea. He was becoming delirious from pain and nausea medications. He stopped eating and drinking.

Despite the use of medications to raise his blood counts, they continued to drop, and he developed fevers. This condition, called “neutropenic fever”, is very serious. The body’s usual defenses have been destroyed by the chemotherapy, so any infection can turn deadly.

He continued to decline hourly. I spoke to the oncologist. I said, “Look, the whole family is here, they need to know what to expect. You do this every day. To me, he looks like he’s dying. Am I missing anything?”

“Well, it’s his first round of chemo, we really have to keep going. I know his counts aren’t really coming up, but, well, you know.”

I found this to be an unsatisfying response. His blood pressure was dropping. If things continued, he would likely be on a ventilator in the ICU by morning.

I’ve known Mr. D. since my first year in practice, so I know him about as well as a doctor can know a patient. I sat down with his family, explained that if we did have to put him in the ICU on a breathing machine, chances were he would never leave the hospital. They had already figured this out on their own. We decided to change him to hospice care.

The next morning Mr. D. woke up. He concurred with the plan and reiterated that he would never want to be on a ventilator. I sat down with him alone for a while. I asked, “So, what do you think?”

“I’ve pretty much resigned myself to what’s going to happen. I can’t even think about eating or drinking. My back is feeling a little better.”

We sat for a while after that.

“It’s a helluva thing, Doc. You come to the hospital for something; it never occurred to me I might never go home again.”