Narratives in Oncology
Breaking Bad News in Bolivia JOSE´ R. GERMA` -LLUCH Institut Catal`a d’Oncologia, Hospitalet de Llobregat, Barcelona, Spain
“But, doctorcito, the treatment might be very expensive!” “Although I only have a slight idea about the cost of treatment in this country, I guess it must be,” I told her, feeling a bit miserable. At that point, the mother looked at me, made the child stand so that I might see him even better than before, and asked with extremely delicacy,“Doctorcito, before we must sell all our belongings, I want to hear you say that you will cure the child, without any doubt.” “I am sorry, señora,” I said to her,“but it is impossible for me to promise the healing of your boy. This sort of cancer is a difficult tumor to cure.” At that moment, the mother looked at me peacefully for the first time in the visit and then said something I will remember for the rest of my life. “Doctorcito,”she said,“doctorcito, if you let our boy die, my husband and I will bring you another child without cancer in 9 months time.” After my initial shock, it began to dawn on me what the authentic meaning of the word unessential was, at least in this part of Bolivia. This couple had to make decisions that would not only affect their child but also their entire family and their livelihood. It would seem that after not being able to guarantee a cure, the couple had made peace with a very difficult choice: that their child was not as essential as their own lives. This experience has stayed with me, even years later. It has also affected the treatment of my Catalonian patients. I treat each with a knowing respect of the value of human life, and after all this time, I realize how fortunate my patients are because—unlike this child—they have never doubted that they are, and continue to be, essential. DISCLOSURES The author indicated no financial relationships.
Correspondence: Jose´ R. Germ`a-Lluch, M.D., Institut Catal`a d’Oncologia, Gran Via de l’Hospitalet 199-203/08908 Hospitalet de Llobregat, Barcelona, Spain. Telephone: 34-93-260-77-44; E-Mail: [email protected] Received October 7, 2014; accepted for publication October 10, 2014; first published online in The Oncologist Express on January 5, 2015. ©AlphaMed Press 1083-7159/2015/$20.00/0 http://dx.doi.org/ 10.1634/theoncologist.2014-0396
The Oncologist 2015;20:227 www.TheOncologist.com
©AlphaMed Press 2015
Downloaded from http://theoncologist.alphamedpress.org/ by guest on May 9, 2015
As a medical oncologist for the past 35 years, I have coped with hundreds of occasions in which I had to break bad news. I must confess that before going to Bolivia some years ago, I thought I had witnessed all of the possible reactions that a family could have, but I was wrong. I had traveled through Bolivia for 6 months, seeing patients in several cities. Only 23% of the population is covered by social security; consequently, people often have to sell their personal and family possessions such as animals, some land, or even the house where they are living to get the money necessary to pay for the specialized treatment recommended. On my third day in Sucre, the political capital of Bolivia, I saw a couple and their little child.They were poor and had been waiting for me all day. The child had a sad look reflected in his deep black eyes, and he bore a huge lump on his left cheek.The skin over the lump had a brilliant purple color. I asked his mother, “How old is he?” “Ay, doctorcito, he is 2,” she answered with a tenuous voice. “Doctorcito, he is very sick because he is crying all the time. He doesn’t wantto eat,and heeven refusesthe milkthat my mother milks for him every day from her goat. Ay, doctorcito,” continued the mother without interruption, “What is wrong with him?” After examining the child, I was convinced that some sort of sarcoma nested inside his left maxilar sinus. “Is this a bad disease, doctorcito?” said the mother with agony. “I am afraid it is. Fortunately this kind of tumor can be treated successfully with a combination of chemotherapy and radiotherapy,” I answered with the same conviction as I would have in my country. “I am sorry, doctorcito,” the mother interrupted me.“What do you mean with these strange words?” “I mean, he needs some special medicines combined with some sort of therapy.”
Breaking Bad News in Bolivia JOSE´ R. GERMA` -LLUCH Institut Catal`a d’Oncologia, Hospitalet de Llobregat, Barcelona, Spain
“But, doctorcito, the treatment might be very expensive!” “Although I only have a slight idea about the cost of treatment in this country, I guess it must be,” I told her, feeling a bit miserable. At that point, the mother looked at me, made the child stand so that I might see him even better than before, and asked with extremely delicacy,“Doctorcito, before we must sell all our belongings, I want to hear you say that you will cure the child, without any doubt.” “I am sorry, señora,” I said to her,“but it is impossible for me to promise the healing of your boy. This sort of cancer is a difficult tumor to cure.” At that moment, the mother looked at me peacefully for the first time in the visit and then said something I will remember for the rest of my life. “Doctorcito,”she said,“doctorcito, if you let our boy die, my husband and I will bring you another child without cancer in 9 months time.” After my initial shock, it began to dawn on me what the authentic meaning of the word unessential was, at least in this part of Bolivia. This couple had to make decisions that would not only affect their child but also their entire family and their livelihood. It would seem that after not being able to guarantee a cure, the couple had made peace with a very difficult choice: that their child was not as essential as their own lives. This experience has stayed with me, even years later. It has also affected the treatment of my Catalonian patients. I treat each with a knowing respect of the value of human life, and after all this time, I realize how fortunate my patients are because—unlike this child—they have never doubted that they are, and continue to be, essential. DISCLOSURES The author indicated no financial relationships.
Correspondence: Jose´ R. Germ`a-Lluch, M.D., Institut Catal`a d’Oncologia, Gran Via de l’Hospitalet 199-203/08908 Hospitalet de Llobregat, Barcelona, Spain. Telephone: 34-93-260-77-44; E-Mail: [email protected] Received October 7, 2014; accepted for publication October 10, 2014; first published online in The Oncologist Express on January 5, 2015. ©AlphaMed Press 1083-7159/2015/$20.00/0 http://dx.doi.org/ 10.1634/theoncologist.2014-0396
The Oncologist 2015;20:227 www.TheOncologist.com
©AlphaMed Press 2015
Downloaded from http://theoncologist.alphamedpress.org/ by guest on May 9, 2015
As a medical oncologist for the past 35 years, I have coped with hundreds of occasions in which I had to break bad news. I must confess that before going to Bolivia some years ago, I thought I had witnessed all of the possible reactions that a family could have, but I was wrong. I had traveled through Bolivia for 6 months, seeing patients in several cities. Only 23% of the population is covered by social security; consequently, people often have to sell their personal and family possessions such as animals, some land, or even the house where they are living to get the money necessary to pay for the specialized treatment recommended. On my third day in Sucre, the political capital of Bolivia, I saw a couple and their little child.They were poor and had been waiting for me all day. The child had a sad look reflected in his deep black eyes, and he bore a huge lump on his left cheek.The skin over the lump had a brilliant purple color. I asked his mother, “How old is he?” “Ay, doctorcito, he is 2,” she answered with a tenuous voice. “Doctorcito, he is very sick because he is crying all the time. He doesn’t wantto eat,and heeven refusesthe milkthat my mother milks for him every day from her goat. Ay, doctorcito,” continued the mother without interruption, “What is wrong with him?” After examining the child, I was convinced that some sort of sarcoma nested inside his left maxilar sinus. “Is this a bad disease, doctorcito?” said the mother with agony. “I am afraid it is. Fortunately this kind of tumor can be treated successfully with a combination of chemotherapy and radiotherapy,” I answered with the same conviction as I would have in my country. “I am sorry, doctorcito,” the mother interrupted me.“What do you mean with these strange words?” “I mean, he needs some special medicines combined with some sort of therapy.”
