One day, an elderly couple that normally sees another doctor at our practice came to see me. Their problem? Not enough pain killers…

You see, Mrs Smith (not her real name) had a type of skin cancer that had spread all throughout her body. Without being crass, the cancer had unfortunately originally been on the labia of her vagina, and by the time it was diagnosed, it had already spread aggressively. After surgery to remove the lesion, multiple courses of radiation and chemotherapy, the spread of the cancer was unrelenting. It was at this time that her oncologists and gynaecologists advised that she and her husband should prepare for the end, as there was nothing else that could be done. So my colleague and the local palliative district nursing service were providing comfort care for Mrs Smith. She was already on a continuous infusion of morphine at extremely high doses and was utilizing enormous doses of breakthrough pain killers.

After discussing her pain medication, we decided to increase the dose of the continuous infusion cautiously and I advised follow-up with their regular doctor. The consultation came to an end and as I bid them good-bye, they profusely thanked me and Mr Smith said that they would come see me again. I did not think much of that statement at the time.

One week later, Mr and Mrs Smith were back in my office. I was somewhat surprised, particularly as I knew that my colleague was certainly available to see them today, but was happy to see them all the same. I was ready to discuss further pain management or perhaps help alleviate an unwanted side effect until Mrs Smith told me why they had come to see me that afternoon.

“I’m worried about cancer,” she said fairly bluntly.

“Your worried about your cancer? In what way?” I asked sympathetically, trying to understand what she meant.

“No, not the cancer I already have, but another cancer.”

“Oh?...” I think I managed to say while waiting for more information.

Mrs Smith told me about how her left breast began to feel heavy and she was worried that she was developing breast cancer.

“I see,” I said, trying to pick my words carefully, not entirely sure where this was all headed. Here was a palliative patient with inoperable, unmanageable metastatic cancer presenting with concerns over another cancer. “Is it causing you pain?” I managed to ask simply.

“No. No pain. It just feels heavy,” she responded. She went on to explain that she’d like to have some tests to look into it.

I could feel my brow furrowing as I asked my next question, “well if it is cancer, and we confirm it on these tests, what would you want to do about that?”

“I’d want it treated, doctor,” she replied simply.

“She also needs a new lump cut off her vagina, doctor. It looks ghastly!” added Mr Smith unhelpfully.

“Wait a second,” I said, my confusion palpable, “you’re telling me that if you had breast cancer you would want that treated even though you’re being palliatively managed for another cancer that has already spread? And you want further surgery for the site of the original cancer?” They looked at me quizzically as if I was being strange. “Mr and Mrs Smith, do you know what palliative care means?” I asked slowly.

“Of course, doctor, it means comfort care” Mrs Smith said.

“Well if there is a cancer in the breast that is not causing any pain, why would I subject you to the discomfort and hassle of further tests, biopsies and appointments if we are only going to treat the cancer with comfort care only?” I was hoping logic would win the day.

“Because doctor, we don’t want that cancer to spread as well,” Mr Smith said, as though I were the one who didn’t understand.

This consultation lasted for an hour. I won’t bore you with my attempts to explain and reason with the couple. All that you need to know is that with every attempt I made, Mr Smith became even more obstinate in the decision to investigate, refer, and aggressively treat whatever was found. Mrs Smith was silent for most of the remainder of our time and seemed resigned to whatever decision was made by her husband, despite my attempts to focus on her and her wishes. In the end, I advised that it seemed that the couple did not understand what palliative care was and recommended a family meeting with the district nurses, GPs, and any available specialists as well as any of their significant others, to fully unpack Mr and Mrs Smith’s understanding of the situation and Mrs Smith's wishes.

It was a messy consultation that left a bad taste in my mouth, as I’m sure it did in theirs. After calling the district nursing staff responsible for Mrs Smith’s palliative care, they gave me a keen insight – this couple were in denial, particularly Mr Smith. Despite many conversations and consultations, Mr Smith seemed to see-saw back and forth on the idea of palliation and wanted to find a doctor who would tell them that more could be done, and that life could be prolonged. The nursing staff informed me that was why they had seemed to abandon my colleague, as he was also reiterating the same information I had given them.

Mr and Mrs Smith did not see me again. I don’t know what has happened since I saw them or how their story ends. All I hope is that they find some peace and dignity with the time they have left with each other.