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.