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Gold

A woman in her 70’s came into my clinic last week. Her primary doc found a mass so she came to the hospital for a biopsy and passed out on the table so they scanned her head and found a mass there, too. She started radiation and then came to meet me in the outpatient clinic.

She had trouble expressing herself because she’d had a stroke two decades ago, but it didn’t interfere with her comprehension. She and her husband had found their rhythm – she mostly answered yes and no to questions, and for more complex answers she’d flick her gaze over to him and he’d supply the answer she couldn’t manage, and she’d confirm ‘yes.’

When I first meet a new patient I try to ease into the cancer discussion (usually to the consternation of my more time-pressured attendings) so one of the questions I asked her was how long she and her husband had been married. She said, ‘ten.’ He said, ‘No, you know that’s not right,’ and she looked to him for help. ‘You want me to tell him?’ he asked her and she nodded.

‘Fifty years, he told me, like he couldn’t conceive a finer achievement. They were 19 and 20 when they married and I’m not overstating the vibe between them, I felt like I was like watching The Notebook.

We reviewed her images and the details of her type of cancer and what the different treatment choices might be. I tend to repeat myself a lot during these conversations because nobody ever hears it all the first time through. When we were nearing the end of the visit, the patient’s husband asked, ‘so, could you tell us what stage of cancer this is?’

Which, shame on me, is a piece of information I had assumed they’d already been told. If there’s one thing that anyone who has ever known anyone with cancer knows, it’s that stage IV is the stage you don’t want, and I’d been carrying on the conversation without first gauging depth of their understanding.

I told them, and it was not what they had been expecting. They both broke into shocked tears, so I took a minute not to say anything and gave them space, which they took. Five decades together and it wasn’t difficult for them to find each other in that moment without my presence making a difference.

I’ve had to tell a few other people this type of news, and there was a difference this time. Most people deflate into themselves, and you can watch their world change by watching their face. Everything else in the room goes away, and their chin lowers to their chest and their shoulders sink inward and their world fills with noise and nothing else you say to them after that means anything.

This woman looked over to her husband, who still cried and his voice cracked when he tried to talk. In his mind, his response was both of their response because he was so used to filling in the gaps for her, now hindered by his inability to get out full sentences. She cried too, mostly silently, and watched him. The expression on her face was not what I typically see in this setting: her eyes were tearful and open and full and fixed on him, not threatened or frightened like most who have just received this type of news. She seemed almost wistful.

‘You’re sadder for him than you are for yourself, aren’t you?’ I asked. She nodded and cried more. They were so absorbed in each other, and so flattened by the news that I gently ended the visit and let them stay in the room until they chose to go. We didn’t make any decisions about treatments and didn’t talk any more about median survival or risks and benefits of chemotherapy.

Sometimes my job is to talk, but during this visit my job was to watch. To watch how fifty years of life together makes a terminally ill woman grieve for her partner rather than for herself because she knows how profound his loss will be. To watch and not to speak because I was in the presence of two people who had become what they were despite two decades of her being unable to generate a whole sentence, and who had found that in their case, words were generally not necessary.

Walk

Last summer I met with a patient in my clinic who had come to the hospital with leg weakness and his CT scans showed widespread cancer. His type of cancer is rare and treatable with a pill which he had been taking for about a month. He was tolerating it without too much trouble.

During our first visit, he was insightful but overwhelmed. “I know how sick I am – just get me to December, that’s all I need.” He had a family milestone coming and told me he would be happy if he made it just one day beyond. Toward the end of the appointment, we reviewed everything and for the first time his emotions came through. “I don’t know what I did to deserve all this,” he said, meaning the weakness and the pain and the cancer in general. It wasn’t self-pity, it was honest confusion.

He made it to December. We celebrated with him and I started to look forward to his appointments as a highlight of my week. He told purposefully bad jokes and needled me every visit about not bringing him a danish and coffee. At the end of each half-hour he would say thank you and meant it.

A few months ago, we ordered a CT scan to check on how all of his different sites of cancer were responding, and one area was much bigger so we switched to a newer pill that hadn’t been available when we started his treatment. None of his symptoms had gotten significantly worse. A few weeks later I ordered another scan to see if the new pill was working and that same spot had grown much more. Not working. His lab work was starting to reflect it as well, so decisions about the next step in his treatment would need to be timely.

The next step was chemotherapy. Here’s the conflict with chemotherapy in patients with stage 4 cancer: most of the time, stage IV cancer is incurable. Just thinking and writing that sentence feels like I’m squashing hope for a thousand patients to come whom I haven’t even met yet. Maybe soon a treatment will be approved that will cure metastatic cancer, but today this happens almost never. So we give chemotherapy to prolong someone’s life as much as we can, but the trade off is choosing among nearly inevitable side effects. It can’t be a decision made without careful consideration.

I’ve already had more than one patient’s family member ask me if it’s ever worth going through chemo for metastatic cancer after their family member had passed away. Sometimes yes, sometimes no, is the best answer I’ve been able to come up with so far.

We talked about it and my patient wanted to go ahead and try it. We scheduled it for the next week but for a few different reasons we postponed for another week when he came back in. Over the weekend he got much sicker and died the following week, never having had the treatment.

He will always represent for me the cancer journey well traveled. It’s never a good road to walk, but he started off toward his self-ordained Promised Land and he was fortunate to have made it. When his disease progressed, he wasn’t bitter and he didn’t rage against the injustice of it. He got to where he wanted to go.

During our last visit, he said another thing. He had clearly been reflecting and had been thinking back to his months overseas in the service when he was young, on all the friends who weren’t fortunate enough to join him on the trip home, and he told me he felt like everything he had after that was a gift. His family, his job, his life.

Almost like he was saying that he didn’t know what he had done to deserve all this.

He died and I’ll miss him even though I never knew him in any capacity other than as my patient. I looked forward to seeing him because I knew I’d laugh at some point when I did, and because he didn’t fall into the trap of focusing on the injustice and inequity that advanced cancer sets for us.

He walked his road, and he made it to the end of it, and then he proudly and gratefully stopped walking.