An NCI-designated Comprehensive Cancer Center
By Michael Easterling | September 18, 2019
Jessica Appel | City of Hope Jessica Appel and her children made cupcakes together in her hospital room.
At just 33, Jessica Appel knew that her time was running out. Hers was an aggressive form of acute lymphoblastic leukemia (ALL), and she was not responding well to treatment. Still, her story has a bittersweet ending — thanks to the many City of Hope employees on her care team who did everything they could to allow her to pass away on her own terms.
Michelle Rouse was her social worker.
“As it was getting toward the end — and she bravely knew that it was — she said she had three wishes: to be able to do something meaningful with her children, to return to her native Mexico and enjoy street tacos and a cerveza one last time, and to be buried near her father in Tijuana,” Rouse said.
Appel’s children never missed school during her illness. Education was very important to her. When they arrived at her hospital room after school, the time had come to tell them that their mother would not be around much longer. They received the news with the help of staff in Child Life Services, part of the Department of Supportive Care Medicine, and then the care team got busy on Wish No. 1.
“Jessica said that back home in Mexico they enjoyed baking together, and she missed that,” Rouse said. “One day her daughter saw a commercial on TV about baking Nutella cupcakes, and that’s what she decided she wanted to do with her mom.”
Rouse brought the ingredients to Appel's room and she and her children made cupcakes together right there. Rouse had worked out a plan with the cafeteria kitchen to get the desserts baked so they could then be frosted and decorated by Jessica and the kids. Meanwhile, the ever-inquisitive young son decided he wanted to “interview” his mom about her life, sitting at the edge of her bed.
“You would think it would be such a heartbreaking, sad time for everyone, but it wasn’t,” Rouse said. “The children had just learned that their mom was going to die soon, and yet there they were having fun with her, smiling, laughing and enjoying the cupcakes. It was sweet.”

Returning to Mexico

With time not on their side, Appel’s care team mobilized to grant Wish No. 2. Her physician, Chatchada Karanes, M.D., a clinical professor in the Department of Hematology & Hematopoietic Cell Transplantation, was afraid for her patient to travel, but understood it was quite literally her dying wish.
“It was due to the teamwork between the medical staff, supportive care and her family that we were able to make sure she went back to Mexico for her final days," Karanes said. “There were no medical options for her left. That’s when palliative care plays such a crucial part. Dr. Mooney made sure she was comfortable on the way back home and Michelle had a major role in making Jessica’s last wishes come true.”
“We looked at all options to figure out a way to make this happen,” Rouse said. “An ambulance would only go as far as the border and it would cost a minimum of $800, and the family didn’t have the money.”
But Appel was begging to go back home for her final days. The Department of Supportive Care Medicine stepped in again and came up with a solution: a family member would drive with Jessica in one car, and other family members would follow with her children. Hospitals were located along the route in case they needed to pull over for any reason along the way. “What we discovered was there is no palliative or hospice care in Mexico,” Rouse said. Karanes coordinated with Appel’s previous oncologist in Mexico, and Appel was sent on her way with enough medications to keep her comfortable on the three-plus-hour journey.
Stefanie Mooney, M.D., assistant clinical professor in clinical supportive care, had to write a letter that the family could give to the border guards to allow them to enter the country with the narcotics provided to Jessica to manage her pain. “There were no issues at the border,” Rouse said. “Everything fell into place. It worked out exactly the way it was supposed to.”
As soon as the family got back to their hometown, Appel got her beer and tacos.
“Jessica was such an inspiring person with such simple, yet fantastic goals for her end of life,” said Mooney. “I think I benefited more from knowing her than she did from me. And I would say Michelle and others on her care team went above and beyond. Our social workers always take things to the next level for our patients.”

Wish No. 3

Two days after returning home with her family, Appel went into a coma and passed away shortly after that, with her husband and children at her side. She was laid to rest next to her father, her final wish granted.
With patients like Appel, hope is sometimes defined differently. Her hope was to be at home, at peace and happy at the end of her life, and she was.
“You hear people talk about ‘a good death.’ This was one of them,” Rouse said. “Everyone on her care team came through for her, her husband and children helped, and together we made her wishes come true.”

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