Death feels like the antithesis to life, the polar opposite, the final terrible full stop to the sentence of existence. But dying, as clinical medicine has taught me, involves an amalgamation of choices and conversations, if one is lucky. As I rotated through oncology, I was prompted to think of death as a negotiable process, and as something other than the worst fate imaginable.
One sunny morning, I was asked to assess a lovely patient in her late eighties with a new recurrence of her bladder cancer. We waved at each other in the hallway as the nurse escorted her and her son into the examining room. As I skimmed through her chart before going in to meet her, I felt an anxiety building within me. I don’t know why it was this patient in particular that caught me off-guard and made me so uneasy; could it have been the kindly wave? The words “invasive” and “aggressive” danced mockingly on the screen in front of me, and as I read further about the woman’s bleeding and weight loss, I felt my anxiety come to a head. I recalled from my pre-clerkship lectures facts about signs, symptoms, prognosis; I imagined the cancer taking root in her insides as she sat oblivious in the other room.
Before going in, I thought to myself, “We are about to ruin all of this lady’s plans”. I had a strong urge to run away in order to avoid the interaction altogether. Wouldn’t it be better for both parties if we simply never shared the news with her?
I unwillingly but dutifully proceeded to take her history and do a physical. She was clever and grandmotherly and had a feisty twinkle in her eye, like a character pulled from a novel. She confessed that she was quite nervous to hear about her imaging results, and her son reached out to grip her hand. When standing outside the room later, I felt the guilt roil my stomach again. Scenes of terminal sickness from various movies and shows I’d seen flitted through my mind. I was afraid of taking on the part of the grim doctor, the bearer of bad news, and playing an active role in upsetting this lady’s prospects. Fortunately, the staff oncologist arrived before I could capitalize on the thought of bolting and we went in to see the patient together.
She started with the simplest question: “What is your understanding of where you are with your health?”
“I think you are to tell me that I have cancer again,” the patient said. I held my breath and waited for her tears.
The oncologist began. She described the situation in no uncertain terms – the recurrence, what the cancer was, why it might have come back. How it had wormed its way through tough layers of skin and muscle, but how we all understood that to be a not uncommon occurrence after the many years following initial treatment. Then the oncologist spoke the words which I was dreading, on the patient’s behalf, to hear: “At this point we cannot cure the cancer; you will, unfortunately, die with this.”
The son put his head in his hands, curling his fingers tightly into his hair.
The oncologist continued. “The good part is that there is nothing dangerous or life-threatening happening to you right now.” The patient nodded again, but slowly. We all took a breath.
What I witnessed next was a plan spun from the hands of both doctor and patient; it unfolded with details about next steps, what the following few weeks and years may look like, and what we would do for her if ugly symptoms made their appearances. There would be no more invasive tests, or aggressive chemotherapy or radiation. Instead, we would focus on preserving life. The oncologist finished with, “For now, you go home and have your evening tea with your husband, like you always do.”
By the time the oncologist left the room, the patient was smiling, ribbing her son on his choice of summer footwear on a snowy day, and gathering her things with relief. I was dumbfounded. Hadn’t we just told her the worst news of her life? Did I not witness the same conversation of which she was the subject? Noticing my dismay, she winked at me and said casually, “It’s such a relief to know, you know. I’m alright!”
Reflecting on that interaction, I understood for the first time that there are worse things than having it confirmed that one is dying. This lady was sure to pass away in a few months at best, but the news was handed to her in digestible parcels which kept her in control of the process. The conversation was handled in a way that put her at the centre of her illness, instead of letting tests and academic interest reign. More importantly, it illuminated the unknown for her, which was more of a terror than death itself.
One physician clarified it for me afterwards: we will all meet our end eventually and it’s not for us to decide where or how or when that will happen; it is more important to focus on the privilege and responsibility of this discipline to guide patients and their families through the process. A recent review underscored this concept and further described that contrary to common assumption, it has been evidenced that communication about goals of care and end-of-life issues does not increase patient anxiety, depression, and/or hopelessness. It moreover pointed out that it is common to experience anxiety as the care provider as well.
The glimmer of understanding is there: experiencing discomfort while dealing with death is natural. But for many patients, the loss of control that follows a difficult diagnosis may perhaps supersede their fear of mortality. I was lucky to witness a skilled physician guiding their patient through this deeply emotional and difficult time; now I must find that voice in myself.
The writer would like to thank to Drs. Beatrice Preti and Michael Sanatani for their encouragement and support in writing this piece.
Editor’s Note: consent was obtained from both the patient and the oncologist preceptor.