My young colleagues,

It is an excellent opportunity to communicate with you through this unique platform. You, on your own, or from your senior colleagues will learn a lot about principles and practice of modern oncology and help the society, in more than one ways. These days management of a patient with cancer is well planned – from the outset to a final outcome, whatever that outcome could be!

I will try to broach upon a different topic today.

When I moved to Bombay (now, Mumbai) in May 1981, to train in oncology, I was instantly staggered with the city medicos' love affair with the abbreviated form of various medical words and sentences. One that completely floored me was, “No R/S” – a cryptic lingo that was well understood by older physicians and the medical record department of Tata Memorial Hospital (TMH). It meant, No Return Slip; in other words, “Please do not return for follow up. We tried what we could.”

It was that simple for us to write in the case file – a closure of sort. However, it kept on disturbing my conscience. In subsequent years, I stopped writing those two words and tried to give a short case summary, using some words of comfort, scaling down the harshness of reality. Of course, it was not possible to do for all, in an insanely busy hospital like the TMH. My language evolved from the often harsh medical terms to milder tones. That was our palliative care.

At times I address my audience who are usually younger colleagues and ask – “have you ever handed over a Death Certificate to a patient?” No one can imagine doing that – a death certificate to a person who is alive! But, you have always been doing that. To emphasize the point, I tell the story – half-truth and half-fiction. It goes like this.

The Envelope in the Front Seat Pocket

He sat quietly in the window seat… aloof… looking out of the small aeroplane window… while I took the middle one. With a detached interest… he looked at the loaders, security people and other ground staff, moving around, purposefully. He didn't turn around, when I took my seat… the stubbly face had no expression… the eyes showed no sign of hope….

A few moments later he took out the printed paper from an envelope… read it …perhaps for the fortieth time… the envelope looked hassled many times over… at the bottom of the paper was a signature above a printed name… as he went on, his eyes appeared more tragic… he folded it slowly and put inside the envelope and placed in the seat pocket in front of him.

He looked in his early 40s, hair, not combed properly, was salt and pepper… clothes, apparently not changed for a couple of days…I wondered, did he lose his job?

When the cabin crew came with the breakfast, he shook his head imperceptibly… not many would've… he didn't touch the newspaper either… I wanted to speak to him… but his shut eyes didn't allow any eye contact.

Three hours later, the plane landed…. I got up and took a couple of steps behind to get my backpack from the overhead bin… he too got out and went ahead… there were people between us… waiting for others to move. I suddenly noticed that he left the envelope behind…. I stepped in to pick it up… a few more passengers jostled out meanwhile… by the time I could get out, he disappeared in the crowd.

I looked at the opened envelope, not knowing what to do with it… perhaps his home address is in the letter… hesitantly, I pulled the letter out …printed in the third line.

Diagnosis: Relapsed acute leukemia

Next line - Advice: Comfort and supportive care…

I was numb… he was alone… with no family, no friend on this last journey… no one to support… as he was returning home… nothing to look forward to… his mind apparently deep in thought for the young wife and the small daughter… possibly old parents too…

I walked ahead… with the envelope in hand… how do I hand it over? There was an address inside. I will mail it to him… would he be around to read it one more time? Coming out, I got a glimpse of him as he got into a taxi… did he leave the envelope behind deliberately?

(It's a tribute to a man who I knew and fought very bravely, all alone… we discussed openly… I realize, many of my friends reading this… have families/friends, going through…).

Conflict of Interest

There are no conflicts of interest.

Address for correspondence

Publication History

Article published online:
03 June 2021

© 2019. Indian Society of Medical and Paediatric Oncology. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

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