The Gift of Life

It all came flooding back when I opened that box.

One day, after a long shift at the hospital, I spotted the golden-brown allure of a small UPS package sitting by my front door. Unable to remember any recent late-night purchases, I tore open the box with curious excitement. Inside, I found a mixture of paraffin blocks, H&E-stained slides, over 30 unstained slides, several patient hospitalization discharge documents, surgical notes, CT and chest X-ray films, pathology reports… and a handwritten note.

“Dear Dr. He, these materials are from my father’s past diagnosis and hospital visits. He passed away last week and I would like to donate them to you as a sign of great appreciation for what you did for us. The medical consultations and very personal, empathetic guidance you gave him in the last days of his life helped my father die peacefully at home surrounded by everyone he loved. Although he suffered a lot during his illness, hospitalization, and treatment, he passed away in peace. My family and I greatly appreciate your medical help and spiritual support. I hope these materials might be helpful for you as research and teaching materials for the future.”

Holding the note and package, I could feel my eyes welling up.

I instantly recalled who the sender was – we’ll call him “Kid,” a graduate student from China studying electronic engineering in an American university. Several months earlier, he had contacted me through WeChat (a social platform similar to Facebook) to asked me to establish a final diagnosis for his father, a 60-year-old patient with an esophageal malignant tumor diagnosed as three different entities by three different hospitals. After chemotherapy, radiation, and surgical resection, he suffered from multiple remote metastases and pathological fractures. He and his family members, concerned by the diagnostic discrepancies, were looking for a consultation from an American medical institute.

At the start of his healthcare journey, Kid’s father underwent endoscopic esophageal biopsy at the local municipal hospital and was subsequently diagnosed with esophageal squamous cell carcinoma. He underwent radiotherapy and chemotherapy, followed by a total esophagectomy, at one of the country’s most illustrious military hospitals. The diagnosis after consultation with several famous cancer hospitals in Beijing was “esophageal adenocarcinoma,” but no TNM or pTNM was specified on the final report. Two months later, the patient developed pathological fractures (bone metastases) and subcutaneous nodules. A provincial cancer center performed the biopsy and a lot of immunohistochemical staining, yielding a diagnosis of “neuroendocrine carcinoma, small cell type.” Now at the end of their rope, the family sent medical records to Kid in the US to request a consultation from me.

We can immediately see several problems with the patient’s experience: the nature of the patient’s tumor was deemed different in three hospitals; postoperative pathological diagnosis reports gave no precise pathological or clinical stages of pTNM; the consultation reports were too simple; and the final diagnosis of metastatic cancer was different from the previous pathological diagnoses and seemed completely unrelated to the tumor!

When I got these reports, I felt that I was seeing approaches to clinical diagnosis, consultation, logic, thinking, judgment, and diagnostic report standardization that were totally alien to American clinical practices. I carefully read all of the patient’s original reports and performed routine H&E and immunohistochemical staining. After reading the slides under the microscope, I was pretty sure I was looking at a poorly differentiated neuroendocrine adenocarcinoma of the esophagus and wrote my own one-and-a-half page pathological diagnosis report. I sent my findings to David Klimstra, Chairman of the Department of Pathology at Memorial Sloan Kettering Cancer Center, along with all the original reports (translated from Chinese) and asked him to review them. Within 48 hours, I had his input, so I translated all of the diagnosis and consultation reports back into Chinese, mailed them to Kid overnight, and called him to explain in more detail and offer some advice from an oncologist friend I had consulted on this unique case. The patient and his family were happy to have a clear, concise, and confirmed final diagnosis and even more information on treating his cancer.

Sadly, one week after the consultation, Kid called me in the late evening to say that his father was in the ICU in very poor condition. Doctors said he had days, perhaps weeks, to live, even though he was still in intensive chemotherapy. In a shaky, emotional voice he asked me: at this moment, what was the best thing he could do for his father? He valued my input and wanted to hear what I’d do if I were in his shoes. After a moment to think, I told him this:

“Kid, I am a pathologist who made a diagnosis for your father’s cancer. I am not his treatment doctor; I don’t have the authority to say or suggest how to treat him. But, because you asked me what I’d do in your situation, let me tell you a true story. Earlier this year, my 83-year-old mom was diagnosed with pancreatic cancer. A month ago, she had diffuse metastasis in her liver and lungs. I rushed back home for a family meeting with my father and brothers in which we agreed to let mom stay home – no hospitalization, no further chemotherapy, and no unnecessary treatment other than morphine (I administered it myself) to relieve the pain. My mom passed away peacefully, surrounded by family, while I held her hand. We medical professionals always keep to the rule of ‘first do, no harm.’ When there’s little we can do for patients with highly malignant cancers, it is often kinder to ease their pain or offer spiritual comfort than to keep them going through treatment. I did this for my mom in her final days…”

He didn’t speak for a few seconds after I finished my story – but soon, I heard something break through the static. He said he understood what I was saying and that he was going to book the first flight to China. He was also going to call his family and make sure his father was discharged from hospital into the comfort of his own home. He told me that he didn’t quite have the words to thank me for my advice. I wished him good luck and safe travels and asked him to say hello to his family for me – especially his father. We said goodbye and, before I knew it, the phone call had ended. A week later, I found that package at my door.

I texted Kid a message: “I’m so sorry to hear the loss of your father; please accept my condolences. I am very touched to receive your package. It’s not just from you, but from your family and from your father, and it is a testament to his life and his spirit. It’s a reminder of how much love you all have for him and how you supported him throughout his journey. It’s one of the greatest gifts I have received as a consulting pathologist and I will keep it forever.”

I think some people might have thought that Kid’s gift to me would upset me or make me sad. But it wasn’t a sad thing; it was a happy one. The feeling I have when I hold it in my hands isn’t because it reminds me of death; it’s because it reminds me why pathologists do what they do. We fight for our patients so they can spend as much time as possible with their loved ones; we look for answers where others find none. It was the best gift that someone in my line of work could ever hope to receive. It was a gift of the most important thing to us all – it was the gift of life.