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One patient I cared for about five or six years ago is indelibly seared in my brain. He was a man in his 40s with progressive refractory oral cavity cancer who had traveled from a foreign country to MD Anderson accompanied by his two brothers after receiving several types of salvage chemotherapy at other cancer centers and was desperately seeking additional treatment options. Before seeing the man, I reviewed his medical record and learned that my colleague, who was his primary outpatient oncologist at MD Anderson, had already discussed goals of care and prognosis and had recommended against additional cancer treatment, instead recommending a purely palliative approach. However, my colleague qualified his recommendation by saying that the patient could receive additional chemotherapy if his performance status remained good. The man and his brothers therefore insisted on more chemotherapy,which, unfortunately, caused his platelet count to drop precipitously and led to uncontrolled bleeding from his tumor, which was the reason he entered the hospital. The bleeding was due to diffuse tumor oozing and was therefore not amenable to cauterization or embolization. I was taking my turn covering the inpatient service for a few weeks, so I served as his attending physician during his hospitalization, responsible for overseeing all aspects of his care. I found this situation to be even more daunting than usual because I was meeting him for the first time in the hospital rather than having had the opportunity to establish rapport in the clinic. The patient and his brothers would have to decide within moments whether they trusted me with his life.

I have vivid memories of the scene at his bedside in the intensive care unit (ICU), where intensivists monitored him for uncontrolled bleeding and airway compromise due to the tumor. He and his brothers spoke no English, so I arranged for a language assistant to meet us outside the room. The ICU team was preparing to intubate him to protect his airway, and I had the task of discussing goals of care with an acutely unstable patient whom I had never met; who spoke no English; and who, due to the acute medical issues, could not have communicated even if he spoke English. I entered his room as soon as I arrived without engaging in the usual pleasantries with the language assistant and ICU team in light of the urgency of the situation. My eyes went immediately to the patient, who was struggling to breathe, choking on his own blood, and agitated. His face was a picture of sheer terror as he thrashed around the bed in a futile attempt to find a position in which he could breathe more comfortably. Every few seconds he coughed forcibly, spraying bright red blood in all directions. When one thinks about the “horrors of cancer,” this scene is what may come to mind. I was desperate to find a way to help him ...

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