Learning to care at the end.

The chest radiograph is stunning. Metastatic tumors appear like cotton balls, stark white opacities where there should be only black air, and the faint white brushstrokes of ribs. They tell the story before we even see the patient. Maddy is only 15, and her cancer has progressed. Our team (pediatrics residents, an attending oncologist, a nurse practitioner, and me, a third-year medical student) gazes at the image in silence. Maddy has been receiving chemotherapy for months, coming to the hospital for tune-ups when the side effects become overpowering. This time, it has become difficult to breathe. We were hoping the radiograph would simply show pneumonia. But these are cancer cells and they are multiplying rapidly. We crowd into her room for morning rounds. Maddy and her mother nod when they hear that the cancer has progressed. They are not new to this; they know her treatments and the corresponding questions. No, she has no mouth sores, but her feet feel numb. She is not surprised that her hemoglobin is low, but she doesn’t feel weak enough to need a transfusion. Maybe tomorrow. In the afternoon, the conference room fills for the weekly meeting. Residents, nurses, medical students, social workers, child life specialists, and a chaplain. As we wait for the attending physician to arrive, discussion turns to Maddy. A resident reviews this morning’s bad news. The social worker remarks that Maddy and her mother remain upbeat. After a pause a nurse speaks up: What is the prognosis? How much time is … Address correspondence to Rebecca E. MacDonell-Yilmaz, MD, MPH, Department of Pediatrics, Hasbro Children’s Hospital, 593 Eddy St, Providence, RI 02903. E-mail: rmacdonellyilmaz{at}gmail.com