After the Turmoil, Peace of Mind

John S. Weitzner, MD

My nurse alerted me that our waiting room was filling up with patients, but one patient's appointment was too crucial to cut short. I had finally convinced her to come in for her prenatal visit after several weeks without seeing her. 

Over the past few years, I had been seeing Diane for routine gynecologic care. A friendly, down-to- earth person, her sincerity and warmth made her very likeable. When she told me her news, I was delighted for her. 

"Doctor, I met a wonderful man. He's an attorney, 28, the same age as me. We're getting married this summer. Hey, you never know - you may be delivering our baby someday." Her big smile and bright eyes reflected her happiness. 

Diane and Scott were married in July 1996, and their lives were moving forward positively. With two successful careers, a strong and loving relationship, and everything ahead of them, they seemed destined to enjoy a long and happy life together. 

Married only 7 months, the young couple's picture changed drastically when Scott was diagnosed with metastatic colon cancer, stage IV. The prognosis was not favorable, Diane told me when she called. Devastated, the couple wondered, How could this be happening to them? Their dreams were evaporating rapidly. 

When they came to see me soon after our phone conversation, they did not look like the same couple I had come to know. The strain of the diagnosis was so evident. A subdued mood replaced the one I had usually associated with them. 

"We were going to wait to have kids, but now we want to get pregnant as soon as possible," Diane told me. "Once Scott starts his chemotherapy next month, his sperm will be affected."

They said they had evaluated all of their options and considered their decision carefully. They were certain that the choice was the right one for them, even though he might never get to see his child. I raised a number of issues, particularly my worry that she could experience difficulty being a single mother with a full-time job. She assured me that she possessed a strong support system, including parents and a sister who lived close to her. 

"If we are successful, I realize that I'll be raising our child as a single parent, but at least a part of Scott will live on. When I look in my child's eyes, I will be reminded of Scott," she told me in a soft voice. Her husband was solemn as he assured me that he wanted this baby too. Tears welled up in their eyes as they spoke. 

I found myself identifying with Scott. I was reminded of my own mortality and the realization that we are only here on earth for a short time. The continuum of life seemed particularly clear to me: as loved ones die, new loved ones are born. It seemed fitting that as the couple came to terms with Scott's death, they were thinking about a new life. I could see why he would want this pregnancy. I would, too. However, if I had been in his position, I am not sure I would have arrived at the same brave choice. It takes an unusual couple to forge this idea. I might have thought that in having a baby alone, my young wife would carry too heavy a burden. Conversely, I could imagine that if I were going to die at such a young age, I might want to try to perpetuate my life by having a baby. 

During this month, Diane would ovulate only once, allowing but one chance for conception to take place naturally. We discussed ovulation prediction and intercourse timing. It was their dream to conceive on their own, but as a secondary plan, they decided to store Scott's sperm before the chemotherapy began. The stored sperm was never used. 

On the very day that Scott started chemotherapy, Diane came in for a pregnancy test. I could barely contain my excitement as I told them, "Your pregnancy test came back positive." They were thrilled. They had conceived naturally. 

Diane's pregnancy was progressing well, but after 6 weeks of chemotherapy, Scott's condition was worsening as the cancer spread. It was a harsh contrast to see him growing weaker while his baby grew stronger. Diane maintained a vigil at his bedside. To be with him, she was neglecting to come in for her prenatal visits. Her devotion to him was fierce. When I tried to reach her to persuade her to come in, she called me back on my cell phone. "I don't want to leave him. He doesn't have much time left." (Like many of my patients, Diane had my cell phone number. I worry about my patients if they miss or cancel appointments, and I want them to know they can contact me if they need me.) 

Her family urged her to see a more conveniently located obstetrician - gynecologist, but she refused. Although my office was an hour's drive away, she did not want to make any changes. She felt her life was in too much turmoil already. 

Worried that she was not getting the prenatal care she needed, I promised her that if she came in for a checkup, I would perform an ultrasonogram of her fetus and make a video that she and Scott could watch together. She made an appointment, cancelled it, then made another, and cancelled it yet again. At 19 weeks of gestation, she finally came in, accompanied by her sister. 

Diane almost cancelled this appointment too. Scott had been discharged from the hospital to spend his remaining time at home. "What if I get back and he's gone?" she asked. On reflection, I realized she believed that if she left his side, he would die - and she couldn't bear not to be there with him when he died. Although I understood how she felt, I reminded her that she and their unborn child needed care as well. I was also concerned about the extraordinary stress this difficult scenario was causing. 

At our appointment, we discussed his feelings - his fear of death, his pain, his sadness. They had not explored these tender issues openly. "Talk about his prognosis," I advised. "Expressing yourselves freely lets you share the pain completely and brings you closer." (I am accustomed to offering this type of guidance, as couples so often avoid addressing "the elephant in the room.") She agreed that it would be important to initiate this type of dialogue with her husband. 

After we talked, I performed the ultrasound examination, which is one of the things I enjoy most in my practice. Diane and I spent a long time looking at the baby's face, the beating heart, the little legs kicking, and the tiny hands and feet. At one point she exclaimed, "The baby is praying!" And there was no doubt about it; the hands were poised, hand to hand, in a prayerful position. 

She took the video home with her and played it for Scott that same evening. The next day, she called to thank me. 

"I took your advice and had a heart-to-heart talk with Scott last night. Then we watched the video together. My sister, my mother, and Scott's mother were there, too," she began. 

"He has been in so much of a daze the past several weeks that focusing long enough even to read a simple greeting card has been too difficult for him. But he watched the video, all 35 minutes of it, and was completely entranced. He couldn't take his eyes away from it. He kept saying how beautiful our baby was and how lucky he was that he could see our child before his own death. We were together as a family - father, mother, and baby. I feel that Scott truly achieved peace of mind."

She paused, crying. I cried too when she said, "and then in the middle of the night, Scott died."

I cry rather easily, so I was not surprised at my own tears. I was relieved to release my emotions in that way. I was overcome with sadness, because her loss was also my own. I was awed, and even felt a physical chill, when I realized he had died just hours after watching the video of his baby. 

Sometimes, when patients are suffering from a terminal disease, they may be holding on for a reassuring event or a sign of some kind. After that occurs, they can let go and die with a peaceful heart. That is what I feel happened when Scott died shortly after watching the video. The significance here, for me, was that the video, which was my idea and something that I had made, had a major effect on this family. 

I was touched by his death for a very simple reason. We are all vulnerable to experiencing the pain of the death of someone else because we are all mortal. When someone dies, at some level we realize that it could just as easily have been us - or someone we love dearly - and although I consider all of my patients to be like family, perhaps the ones who endure more tragedy become even closer to me. Dana was born 17 weeks later, on December 21, 1997. I am in frequent contact with Diane, and she remains my patient. She recently told me that, in addition to the videotape, I had given her some still pictures from the ultrasonogram. One of these, a picture of the fetus' hands together, was so meaningful to her that she displayed it at her husband's wake and placed it in the casket. Diane also placed a copy of this picture in their baby's room, where it has remained ever since. 

About 3 years ago, I received great news from Diane. She had been lucky enough to meet another wonderful man. I met Andy when Diane came in for an office visit. I was impressed with how attentive and caring he was toward her. When they married, in September 2006, I felt unexpectedly relieved. I realized that I had been carrying the weight of worrying about her, simply because she and her daughter had become so special to me. 

Her daughter had longed for a sibling for many years. During a visit to my office, Diane and Andy revealed to Dana that she would finally be getting a brother or sister. She was almost 10 years old at the time and reacted with delight, with a big smile, and said, "Mommy, you're pregnant!" as she saw the ultrasonogram of her sibling-to-be on the monitor and saw the embryo's heart beating. In May 2008, Diane gave birth to a boy, and now Dana has a little brother, Matthew. 

Scott's family was found to have an altered gene, which was responsible for the colon cancer. This will have a continued effect on my relationship with Diane and Dana as we closely monitor Dana's health as she grows. 

Although it has been 12 years since Scott's death, Diane and Scott's story remains vivid. The experience of knowing them, and being privileged to accompany them on their journey, still evokes gratitude in me. I believe I became an obstetrician, in part, to help this family. As a result of knowing them, I started taking a deeper look at the big picture, at the role I play in the lives of my patients. 

A case like this one emphasizes the importance of the personal relationship between doctor and patient. The message for all of us as physicians is that you gain a great deal if you allow yourself to become involved, to be touched by the people you care for.

 

Obstetrics & Gynecology. Vol.115, No. 2, Part 2, p. 479-481, February 2010