“But doctor, what about the grandkids? They aren’t old enough yet.”
This is how the tears start rolling down his cheeks, prompting his wife to squeeze his hand.
For years he has been a fixture in the clinic – accepting surgery, chemotherapy, periodic radiation, more surgery and more chemotherapy, each with its attendant complications. Through it all he has been steadfast, until the last few months, when his condition suddenly dipped.
We run through his many treatments, each one a little more disappointing and short-lived than the last. He agrees that he feels weaker and worse. I remark that while modern medicine can always offer “something else”, I don’t believe more chemotherapy is the answer. His wife nods.
He asks why he dreams of a lavish meal but gags at the sight of one – I sympathise that this is what illness does. He asks if he will ever hike his favourite mountain again and I accept the question as reconciliation. Then, a hush before a wordless message crosses between the couple, as if to encourage, “Go ahead, you ask.”
“Doctor, how long do you think I have?”
My room is windowless and featureless. Instead of a peaceful image or an inspiring quote, there is a warning about handwashing and a reminder to complete a survey about “any IT issues”. What I am about to say feels like prescribing a prison sentence to someone already inside the prison.
Without notice, doubt engulfs me, begging me to reject the evidence and run towards safety. The safety of saying no one knows, miracles can happen, or there is something else to try. The safety of rejecting the very premise of his question and telling him we will never give up and neither should he.
I think of the euphemisms we use in medicine. Like explaining a complex skin graft as “taking a bit of your belly to fix the hole in your neck.” Or describing dangerous surgery as “a chance to fix the plumbing”. These phrases sidestep complexity and hope for the best, but I don’t need to be told that a direct question about mortality forbids evasion and demands an honest reckoning.
Conversations about death and dying are commonplace in oncology and I remind myself that I am no novice. Then why does every time still feel so raw and unsettling?
A phone beeps and I step out to let him answer his son’s call which gives me a moment to reflect.
In my 20s, I lacked the clinical experience to know how quickly someone could die from a liver filled with tumour or a brain swollen with blood. I needed to see enough patients to distinguish those who died because of cancer as opposed to those who merely died with it. I had to learn how to apply the stuff of journals to real-life people. These felt like legitimate reasons for sidestepping difficult questions or simply confessing I didn’t have an answer (although I wish I’d tried harder to find someone who did).
I also lacked the life experience to truly appreciate why such conversations mattered. I did not have children. My parents were youthful and my loved ones healthy. My friends played golf, watched plays and ate at fancy restaurants. I lived in a privileged and infinitely optimistic world in which “morbidity and mortality” was just the name of a monthly meeting.
But in the second half of my career, mortality and morbidity became part of my life. I found myself not only treating the “human condition” but also becoming a part of all that it entailed.
Today, I have children whose love warms me and whose vulnerability sobers me. My parents have health scares and need help. My colleagues commit suicide and friends develop serious illness. Birthdays are interspersed with funerals; weddings with separations. Suddenly, no one is invincible – but no one really teaches this to doctors.
Diagnosis, prognosis and everything in between have become real in their implications. Life expectancy isn’t “just an estimate” but a pronouncement that shifts weddings and barmitzvahs. Quality of life isn’t an academic footnote but a metric full of meaning. “If you were unable to speak for yourself, what would you want?” is not only a question for my patients but also one for my family.
Of course, patients didn’t just start caring about their children and grandchildren. Or start resenting illness or rage against dying. These are age-old phenomena that now pulsate with new meaning because I am older. This shared experience of life is what draws doctors and patients closer. It is also what makes difficult conversations harder.
When I walk back in, my patient looks at me expectantly. If I am to earn my privilege, this is no time to bury the truth under an avalanche of platitudes. So, I face him to say that I am sorry his time is limited and that I will help him make the most of it. With palliative care, we will manage his symptoms and respect his wish to stay at home. We will figure out activities he can endure, helping him create a legacy of good memories. I also commend their partnership and reassure them that they have given it their all. He is calm and dignified. I am humbled.
All this time, his wife has been encouraging me with her eyes and now, I acknowledge her support with mine. As they leave, she hangs back and squeezes my arm. “Best of luck with your future,” she whispers. Watching them leave hand in hand, I know it to be both blessing and goodbye.
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