It was a typical day in the life of a hematology/oncology fellow who thought she had mastered the art of multitasking. Hoping to save time, I went to the oncology clinic to see a new patient while nurses were getting her bed ready on the floor.

I was told she had been recently diagnosed with metastatic non–small-cell lung cancer and was now presenting with worsening shortness of breath and dysphagia resulting from extrinsic compression from mediastinal lymph nodes. Accompanied by the internal medicine resident and making a mental list of the patient's admission orders, I entered the room to find a middle-aged woman and two companions. I introduced myself and started asking the initial interview questions. She answered some of my questions but barely looked at me.

After 10 minutes, she paused, looked at me, and said, “You have terrible bedside manners.” Her frustration was obvious and her rudeness deliberate. I was accustomed to receiving praise for my bedside manners, and this was the first time I had received such harsh and direct criticism. I felt the heat rise to my face; I must have looked flushed when I asked, “Tell me why?” I felt the urgent need to sit down and realized I should have been sitting when I first began speaking to her.

“Do you know who these people are?” she asked, motioning to the two friends who had accompanied her. Of course, I did not, because when I had introduced myself to them I had not thought to ask their relationship to the patient. “You are telling them everything about me and you didn't bother to check with me if it was okay.”

With thoughts of potential lawsuits and embarrassment regarding my indiscretions, I apologized. But I was frustrated that she had allowed me to proceed with the questioning for 10 minutes before interrupting me. I felt as if she was testing me, or maybe I was just feeling defensive because of my initial misstep.

Regardless, she was right. I asked if I could continue.

“Yes, it is okay,” she answered briefly, “but next time, you should ask that before you start talking, and I am very tired now. You should really look into the patient's chart before asking the same questions again.”

To respect her wishes and seek some respite, I excused myself and exited the room. I made sure her pain was addressed and also that she was sent to the floor as soon as possible. This had not been a good start, but I left hoping that, with better pain control and more rest along with an extra amount of tactfulness on my part, our next encounter might be better.

As I stepped into her room the following morning, my hopes were dashed. I found her sitting in the chair in pain and short of breath, clearly in distress. I made sure my bedside manners were the best, but she continued to avoid eye contact and answered in what I felt was a passive-aggressive tone, questioning all of my suggestions regarding her care. It was very disturbing to me to see that I was not able to establish a good relationship with her, and I was offended that, despite verbally accepting my apologies, her body language and demeanor contradicted that acceptance. She requested supporting literature for everything that was to be prescribed. I began to question my skills with regard to her management but soon became aware that she treated the entire staff in the same manner. As the days wore on, she continued rejecting everything—from pain medication to respiratory therapy. She would say, “I will read the literature about this and decide later. I know my body better than any of you. I am not stupid.” And indeed she was a very smart woman who was able to reject and deflect all the team suggestions with intelligent and well-thought-out arguments. But unfortunately, she never made any decision regarding her management, even as she became increasingly uncomfortable.

We suggested palliative chest radiation and continued to urge her to make a decision, but she did not. She refused to let us contact her family or friends, telling us that she knew that we could not contact them without her permission. Every possible strategy to reach her, from extreme politeness to tough love, failed. No staff member could breach the wall she had erected. The entire team was feeling impotent in dealing with her situation. Out of sheer frustration and even though we knew the answer before we called for a consultation, we sought the opinion of psychiatry. Their opinion was that she was competent to make her decisions, but they could not elaborate further because the patient did not allow them to stay in the room very long. Because she always had a Bible by her side, we asked the chaplain to see her. After a brief conversation with her, the chaplain reported the patient was wary of attempts to guide her in making a decision.

I learned the patient had lived a lonely life and had always made all her decisions by herself. She was also very suspicious of others, given that she had suffered abuse from her husband. At a follow-up visit, the consulting psychiatrist found the patient extremely short of breath, barely able to speak, and deemed her not competent to decide—likely as a result of her worsening hypoxia. I called the intensive care unit team who proceeded to intubate her. She voiced some reluctance even at that time.

After her intubation, I felt a sense of relief because I thought she would be sedated, more comfortable, and not in pain. But in the back of my mind I also knew that now I would not need to talk to her every day, and I felt ashamed. As the days wore on, it became clear that she would not improve, and her family was finally notified. They were shocked to learn about her situation, but they all came to say goodbye. Then her ventilator support was withdrawn.

After her death, I spent time thinking I had done a terrible job. I wondered whether the outcome might have been different if I had succeeded in convincing her to give us an answer. Although I knew I could not have saved her life, I wondered what I might have done to ease her suffering. With time, I realized that her reluctance to give us answers was actually her answer!

Maybe the reality of her condition was too hard to accept, and none of the solutions seemed good enough. I thought how often we all do that—we avoid a decision and leave it up to destiny or luck. By avoiding the decision we also avoid responsibility for the outcome. Or maybe, for this patient, the real loss was not death or suffering. Maybe, for her, the real loss would have been the loss of control and letting others dictate what she had to do.

I realized that, as oncologists, we are usually eager to solve issues that present to us in our personal and professional lives. We have been trained to respond to conflicts and difficult situations by acting, deciding, and fixing, not by pausing and listening. I also realized that I spent most of the time trying to convince my patient to choose from the options that I was presenting her and very little of my time trying to understand her background, her ideas, and her needs. Maybe if I had been able to put aside my preconceptions and biases and just listened beyond her refusals, I would have been able to help. She taught me that help does not always mean “solve,” sometimes it means “listen.” I learned that, sometimes, just being there for our patients is the best course of action.