When You Can't Have Everything

"You can't have everything. Where would you put it?"
-- Steven Wright

"All I want to do is eat a pork chop again." He communicated through a talking, electronic keyboard. "That's all I want. What are you going to do?"

What hadn't been done already? Part of his voice box had been removed twenty years before. Several years later, part of his tongue and throat had been removed because of a new, large cancer. He had received radiation therapy when his cancer returned in the lymph nodes of the neck. His teeth had all been removed, and he could not wear an effective denture. Additional cancers had led to more surgery. His swallowing mechanism was badly compromised even for some liquids.

Two years ago, his unhappiness led him to a surgeon who agreed to take out his voice box to see if it would help with his swallowing. Unfortunately, it didn't help very much. Botox injections of the throat muscles did not work. Now he was challenging me to come up with another solution.

Traditionally, we think of difficult discussions between patients and physicians in a "linear" format; that is, we assess what the patient knows, tell them the bad news as clearly as possible, and then assess what they have learned. Most discussions, however, are anything but linear. Questions come from all corners of the room. Thoughts overlie questions that run into opinions that overwhelm information.

A recent article about communicating with cancer patients was helpful to me. (Egley S, et al, "Discussing Bad News in the Outpatient Oncology Clinic," Journal of Clinical Oncology 2006; 24:717-19). The authors point out that these types of interactions are not usually predictable and that any news can be perceived as "bad." They also remind us that the information is perceived by the patient in the context of the relationship with the physician. Knowing the patient and family should shape how the information is provided and is perceived.

"When will I eat a pork chop?" he pressed me again. I glumly realized that I am unable to make it possible for a man who has only part of his throat, a partially paralyzed tongue, no teeth, and almost no saliva to eat a pork chop. He sat silently and waited for me to respond. I shifted uncomfortably and searched for the right thing to say. Finally, he broke the ice.

"A head transplant?" he suggested. Our mutual relationship was taking over again.

I exhaled. "I'll look into it," I promised. He grinned.

He left without improving his swallowing, but, I believe, satisfied that he had truly explored all of the available avenues.

Bruce H. Campbell, MD, FACS
Professor of Otolaryngology and Communication Sciences
Chief, Division of Head and Neck Oncology
Interim Director, The Medical College of Wisconsin Cancer Center

"Reflections" is a collection of essays by the health professionals of the Medical College of Wisconsin.