“You’re my last hope.” The words come from a patient I have no prayer of helping. He has had decades of back pain. He has had several surgeries, injections, hardware in, hardware out, but nothing has helped. He is unable to work. His struggle with back pain has ruined relationships, ruined his financial stability, ruined his mental health. His goals and mine are aligned. We both want to make his life better. Unfortunately, I have no operation to offer. His pain has become like a cancer. It’s incurable. It’s invasive. It’s terminal. His words echo in my head after learning about Dr. Preston Phillips, murdered by a patient suffering ongoing back pain after surgery. The patient I cannot help presents many challenges to me as a neurosurgeon. Murder was not one I had seriously considered. The patient I cannot help is the hardest patient to see. I want to fulfill his last hope and tell him I can fix it. It is gratifying to free someone of their misery. The tragic irony is that it is easier to give the “I have nothing left to offer” talk to a patient with cancer than to a patient with chronic back or nerve pain. The finality of cancer is felt from the first utterance of the word. The cancer patient is surrounded by empathy and support. When there is no treatment left, it is crushing but expected. The back pain patient I cannot help does not feel the halo of support. He expects there to be something, anything, that can fix it. There is no finality. “So I just have to live like this?” I tell him I want to help, but today’s medicine doesn’t have an answer for his problem. It’s incurable. He needs a time machine, and I don’t have one. I feel inadequate. Small. Putting myself in his shoes, I understand his deep disappointment. When a person is in pain, disappointment is plentiful. At some point, it becomes intolerable. The cancer of chronic pain has spread to his brain. It’s invasive. Hitting a breaking point, he starts to rant at me about how nobody can figure out what’s wrong and nobody cares. I absorb his verbal tornado. He ends with, “I can’t go on like this.” It’s terminal. I offer my hand, my thoughts, and prayers. “Please, I’ll take any chance,” the patient I cannot help pleads. I admit I have been talked into operating on a desperate patient or two in the past, convincing myself there was a tiny ray of hope that surgery might change his course. The curse of doing spine surgery is that even a perfect operation can’t erase decades of damage. Like Dr. Phillips, I have had patients who didn’t get better after surgery. I failed to bend Mother Nature in their favor. I offer the patient I cannot help a referral to a counselor to help him deal with the emotional upheaval of pain and disability. Boiling under the surface he tells me his insurance will not cover anyone in his region. I make a new referral, hopeful that this time his insurance-for-people-who-cannot-work will authorize the counseling. I search for empathetic words but come up with only empty platitudes. “Hang in there,” I say lamely. He leaves my office. A sour fog hangs in the air. The furrow between my eyebrows deepens. Will he find a counselor or a supportive family member to steer him back on course? Will he quietly pour out his angst against me as a negative patient survey, a complaint to the medical board, or a lawsuit? I had considered these outcomes the worst-case scenario, professional sabotage. Then Dr. Phillips was murdered. The patient I cannot help might buy a gun, shoot himself, and shoot me. It’s terminal. Source
