In the winter of 2014, one of my closest friends, a 44-year-old man, was diagnosed with stage IV pancreatic cancer. Bret had just come back from a 3-week family trip to South Africa. He had been having abdominal pain. He called me to ask for my advice, and I told him he needed to see his regular physician and have a physical. His doctor was my partner. Right after his physical, Bret stopped by my office to catch up. He was his usual robust, incredibly funny, and larger than life self. His blood work had come back normal, exam was equally unremarkable, and he was prescribed an acid reducing medicine for a couple of weeks. Life was good.

Bret’s abdominal pain persisted and started interfering with his sleep, which was unusual for any acid-related condition. I asked him to go back to his doctor. During that visit, his physician thought he palpated an abnormality in his abdomen and sent him for an urgent ultrasound at the hospital down the street from our office. An hour later, Bret’s doctor, my partner, walked into my office and said, “I don’t know how to tell him this, but your friend has stage IV pancreatic cancer.” It felt like time had stopped. I was stunned. I could not reconcile this diagnosis with the image of a 6’3” healthy and fit father of two young children who just joked with me and hugged me on the way out. And those hugs…anyone who had ever been hugged by Bret (and he hugged everyone he liked) knew what it felt like to have his huge arms wrap around your body and lift you off the ground.

I ran to the radiology suite and reviewed the ultrasound with the radiologist. He wasn’t sure it was pancreatic cancer, there was a 6 cm pancreatic mass, but there were multiple lesions in the liver, lymph nodes and the lower portion of his lungs which were captured on the abdominal ultrasound that did not look classic for pancreatic cancer and looked more like lymphoma. When these words were spoken, I felt myself breathing again. Lymphoma we could work with. Lymphoma meant hope. Lymphoma meant life.

I ran back to the office and told my partner to let Bret know that he had a mass in his pancreas and that there are multiple lesions elsewhere, and that we needed a biopsy to know exactly what it was. It was cancer, but we didn’t know what kind of cancer. I told him not to tell Bret it was pancreatic cancer, because we didn’t know that. As soon as Bret finished speaking to his doctor, he called me. He wanted to know what he should tell Deborah, his wife. His voice was sad, so sad that I had to make sure my voice wasn’t breaking, that I sounded hopeful. I told him that he should tell her exactly what his doctor told him. After work, I came to their house. By that time, I had arranged for his biopsy to be done the following day and for me to take him there. He would see my favorite oncologist immediately after the biopsy. We would have an idea of what we were dealing with because the pathologist would look under the microscope right then and there to make sure we biopsied the target lesion and not normal surrounding liver tissue.

The following day Deborah and I took Bret to the hospital. I asked to be allowed into the OR and as the radiologist was a colleague who knew me, he allowed it. I held Bret’s hand throughout the procedure. After looking at the specimen, the pathologist commented “sample adequate, adenocarcinoma.” Bret’s eyes were on mine. I again felt time stop, I don’t think I was even breathing. Bret said, “That’s not lymphoma, is it?”  Tears were forming in my eyes. I looked back at him and said “No, it’s not.” As I said these words, I felt something shift in me, at that moment I knew with certainty that Bret was going to die. His eyes filled with tears, and he didn’t say anything else.

The oncologist told us that Bret had pancreatic cancer. He said we could wait for the final pathology, staining, and genetic testing to come back, or we could start treatment now. He showed us the bell curve and said that with Bret’s disease burden, about 5% of patients are alive at 2 years post diagnosis, but that Bret was young and otherwise healthy and so his chances were better, and he should tolerate chemotherapy easier than most.

Bret wanted to fight. He said, “Oh, I plan on being so far on the right side of that fucking bell curve, you’ll be writing articles about me.” We agreed that Deborah should keep working as Bret would be on disability and they had a mortgage and two kids. Our other friends pitched, some taking care of meals, others helping with carpool for the kids. I’m the only doctor in our friend group, so I took care of everything medical.

For the following 9 months I took Bret to every chemotherapy session, oncology appointment, injection, and procedure. After only the second time we went to chemotherapy, we had our first disappointment; his white blood cells were low. If it was up to Bret, he would have had chemo every day, not every two weeks. He so wanted to fight! But we had to allow his bone marrow to recover from the last chemo first.

When we drove home, Bret called Deborah. He started with the usual, “Hi, angel”. Then he broke the news but with a very positive spin. He told her it was for the best, his body would get stronger, maybe his oncologist could give him a different medicine next chemo to prevent this, etc, etc. All of it was said with such enthusiasm and conviction, that by the end of the conversation, not only Deborah believed this was a good thing, but I saw that even Bret believed it.  And more remarkable, I believed it too!

It was Alex, Bret’s oncologist, who taught me that we should never lose hope; we just have to pick the right thing to hope for. I felt that for the first time, someone was talking to me, understanding that it was really me who needed hope.

We hit many more disappointments and each time, we adjusted our expectations, we hung on to a different hope. At first, I hoped for lymphoma and got everything arranged as quickly as possible to confirm that. When we found out it was pancreatic cancer, I hoped for the chemotherapy to work. Once the chemotherapy stopped working, I hoped for him to be pain free. And when his pain became excruciating, I hoped that the pain medications would comfort him and allow him to finish the book he was writing and to have meaningful time with his family.

Once we exhausted all treatment options, he was referred to a pancreatic cancer specialist at the local university hospital, hoping that he could enter a study. Upon reviewing Bret’s chart, the specialist said that he couldn’t understand why community oncologists “gave patients false hope.” He suggested Bret gets his affairs in order and enjoy what time he had left. Bret and Deborah were crushed. The following day Bret was hospitalized with intractable pain and went home with Hospice. He died shortly after.

I was recently talking to a friend, also a physician, who was in the same situation I was ten years ago, helping a very dear friend who had advanced cancer. We talked about hope. She mentioned that while she didn’t want to give “false hope,” she also didn’t want to take hope away. I shared what Alex taught me about hope. Hope doesn’t have value, it’s neither false, nor true. It’s just …hope.

When Bret was first diagnosed, I spoke to one of my mentors, a retired pathologist and his response was, “Oh, Irene, he’ll be gone in six weeks.” Bret fought for nine more months. During that time, he worked and finished two amazing projects that made a name for both him and his company, co-authored a children’s book with a well-known writer, took his family to Disney Land for his daughter’s 7th birthday, taught a few friends how to surf, continued giving advice to many of his friends, and continued living life to the fullest. Until that visit that terminally executed his hope.

Few people understand how emotionally difficult it is for a physician to take care of a loved one (or a young patient) with a terminal illness. We expect ourselves to be strong and compartmentalize because that’s what is demanded of us. We want to hope for a miracle, but our experience crushes that hope with the reality of worst-case scenarios that we must will ourselves to suppress. We are asked to interpret studies, and we struggle with giving honest answers yet in a gentle way. We rarely discuss our feelings with others because we feel guilty comparing our feelings with what the patient is going through. Even rarer do we seek professional help because we don’t think we will be told anything we don’t already know. Even physicians who have not been in this situation themselves don’t understand; I know I didn’t before I took care of Bret. Had my partner understood this, perhaps the manner in which he told me about my close friend’s terminal diagnosis would have been so much less matter of fact. Perhaps if my mentor understood this, he would have been gentler, more comforting in his prognostic pronouncement.

To this day, Bret’s death was the most painful I have ever witnessed. It has taken me ten years to be able to fully process my feelings of guilt and helplessness. Recently, It took a 42-year-old patient with metastatic cancer for old wounds to open back up.

Irene Teper MD practices Internal Medicine in California