Grief Tacos

Elizabeth Brém, MD
Assistant professor of medicine at University of California Irvine Medical Center in Orange, CA

Life is hard. People are resilient.

I gave birth to our second son this past February. There are some things about the second kid that are easier; for me, this included the acceptance that disconnecting from work as much as possible is a necessity while sleep-deprived and disheveled from having a newborn. Overall, I did a pretty good job staying off our electronic medical record system and triaging emails during the three months I was on maternity leave. My colleagues took excellent care of my patients in my absence. The majority of my patients were doing very well when I returned – in remission from their lymphomas, continuing their maintenance therapies for myeloma, etc. Unfortunately, one of my lymphoma patients was diagnosed with acute myeloid leukemia (AML).

This patient had Hodgkin lymphoma about 30 years ago. I had treated her about two years prior for an aggressive diffuse large B-cell lymphoma (DLBCL); not double-hit, but with Myc overexpression and complex chromosomal abnormalities. I chose to treat her with dose-adjusted EPOCH-R. (Let’s skip the R-CHOP vs. dose-adjusted EPOCH-R debate for the sake of brevity.) When her DLBCL started, she was quite sick, with abdominal pain, significant liver abnormalities, and B symptoms. She always came to clinic with excellent family support, typically accompanied by her spouse and at least one of her three children. Her response to therapy was rapid and excellent. There was some residual neuropathy after completion of therapy, but otherwise she was back to her normal life a few months after we completed the six cycles.

The AML that was diagnosed while I was on maternity leave appeared to be treatment-related, with t(9;11) suggestive that the etoposide (the “E” of EPOCH) may have been the culprit. I felt so guilty when I found out! I know that there always is a risk of secondary malignancies when giving chemotherapy, but this risk typically seems so minimal in the context of potentially curative therapy for an aggressive lymphoma. This was the first time I personally was confronted with such a severe consequence of treatment that I had recommended. When I came back from leave, the patient had just finished her first cycle of therapy for the AML under the care of one of my leukemia colleagues. She had chosen to receive a hypomethylating agent with a tyrosine kinase inhibitor on a clinical trial.

Soon after my return, I started a two-week block as the attending on our inpatient hematologic malignancies service. My dear patient with the treatment-related AML came in with febrile neutropenia. Initially, it seemed like a routine febrile neutropenia admission, but she rapidly deteriorated clinically. Despite appropriate antibiotic coverage, she became hypotensive and confused and was transferred to the medical intensive care unit (MICU).

I met with her family after she was transferred to the MICU. Understandably, they had not quite wrapped their heads around the still-new AML diagnosis, but they were able to engage in an informed conversation about my patient’s medical issues. We discussed her guarded prognosis: To date, there had not been a frank goals-of-care discussion among the patient and her immediate family members, but it was clear everyone knew that the chance of curing the leukemia was low.

While we were having this conversation, a code blue was called on our patient. The MICU team was able to resuscitate her. The patient subsequently was placed on multiple vasopressors, but appeared somewhat stable. At this point, I left the MICU as patients on my service needed attention. While I was rounding, another code was called on her. After about 15 to 20 minutes without return of a pulse, the decision was made to stop resuscitation efforts.

Photographic evidence of “Celebration of Life” tacos.

About an hour after the patient passed, I came back to the MICU family area to see if my patient’s family was still there. The patient’s spouse, three children, and daughter-in-law were there with boxes of tacos, smiling and sharing stories.

The patient herself had been a clinical therapist, specializing in helping clients with grief and loss. Whether it was intentional or not, it appeared that the patient had used these skills to prepare her family for her eventual passing. Rather than debrief about what had just happened or discuss the patient’s clinical course, the family wanted to share tacos and tell stories. They wanted to see pictures of my newborn and pass along a gift for his big brother.

I was impressed by their resilience and touched that they were able to think about me and my family in this moment. I was reminded of one of the key factors that drew me to hematology/oncology: I truly believe that the depth of relationships formed with patients and their families is unlike those in any other specialty. I do not know if they were aware of it, but this family was doing an excellent job practicing Stoicism (see my mid-July “Modern Medicine and Modern Stoicism” editorial for a lesson in Stoicism). The Stoics reminded themselves, “Memento mori,” or “Remember you must die.” You could leave this life at any moment. This is not intended to be a morbid thought but to give us perspective. Live life now; prioritize your thoughts and actions toward activities that are productive and important.

At the time, I sent my husband a photo of what I called my “Grief Tacos.” As I am reflecting on the experience now, I realize that they were really “Celebration of Life” tacos. I am grateful to this family for the unselfish and unsolicited care and closure they provided me. None of us chose this field because it is easy. I hope you all have similar experiences now and again to bring balance and perspective. I wish you all resilience, comfort, and tacos.