the letter

TM died yesterday. this is the letter i wrote to his wife:

dear mrs. m,

i want to tell you how sorry i am to hear of mr. m's passing. for the short time i knew him, i can honestly say that i am a better person for having known him. he had a way about him that exuded faith, confidence, and a love of life. one of my hardest moments with him involved telling him that he could no longer ride his motorcycle--i can't imagine how difficult that was for him to hear. but, he took it in his stride, as he did with his cancer.

i also want to tell you how much you meant to mr. m. from coming to his appointments, to going to motorcycle rallies, to spooning water into his mouth with his medications--i could see his love for you in his eyes when i spoke of you. i understand that you were upset about not being at his side the moment he passed. remember the time you did spend caring for him, all the time you did spend by his side. over the past year, you did everything in your power and more.

i know the coming days will be difficult for you, but have faith that you will get through it. you are a strong person. if you need to talk, please let me know.

____

a comment from the cheerful oncologist, himself! thanks, doc. i will keep writing. of note, i was inspired by the following words from the cheerful oncologist:

"life is only fulfilled when the mind and body are in motion. As long as I can stand and think, I will keep moving - see patients, laugh at jokes, wrestle with my sons, walk the dog, meet my wife for lunch, call old friends - get out and be a part of this great world, not wail in my chair how unfair it all is."

go here for more.

give hope, but prepare for death. part II

i'm trying to be a cheerful oncologist. really. but i just can't seem to get past the suffering. so i use this as an outlet. overall, i'm not a despondent person, but things like this make me wonder aloud about how we continue to live our lives as though nothing is wrong:

TM was one of my first cancer patients three months ago as i began my training. tough guy, leather jacket, tattoos, drives his motorcycle cross-coutry. he has the bad kind of lung cancer--not that there is a good kind. the first day i meet him, i have to tell him that his cancer has spread to his brain despite showing an initially good response.

"i don't want to hear about time, doc," he interrupts me. "i don't need to hear about how much time i have left. let's just do what needs to be done." later on that night, his wife calls me and asks for the gory details. so i tell her.

over the past three months, TM has taken a turn for the worst. he was at a motorcycle rally when he fell and didn't have the energy to get back up again. when i visit him in the hospital he looks tired, different somehow. i sit down next to him in silence.

"you're here to tell me that i'm too sick for more chemo," he sighs.
"yeah," i barely whisper. i find it very difficult to look at this man's man, with the tattoos and the motorbike and the tough build--i find it very difficult to look him in the eyes and tell him he is dying. but this time he wants to hear it.
"so tell me, doc. tell me how long i have." he wants to know the gory details. so i tell him.

he's at home now, under the care of home hospice. i called him expecting his wife to pick up. but he answered, his voice weak over the phone, tv in the background. he has not the strength to get off the couch. he knows his time is near, and i fear his spirit is broken. to die comfortably at home is one thing; to die with a broken spirit is another.

earlier on, when he still walked into my clinic with his chest out and his bald pate shining, he chortled at the comment of the resident who discharged him from the hospital stay: "can you believe this guy, doc? he told me i shouldn't be riding my motorbike? was he kidding me? that's all i got, doc. that's all there is left of me."

i took a deep breath before i said, "mr. M...you can't ride your motorbike anymore."


___

thank you, Chixulub, for your comments. any and all comments are always appreciated.

give hope, but prepare for death.

i've been holding back tears in clinic lately.

maybe it's because i'm tired, or maybe it's because these people are dying in front of me and there is little i can do.

to set the scene: my weekly clinic is at the veteran's hospital associated with Famous Cancer Center (henceforth referred to as FCC), where i am for most of my oncology training. this is a common setup at training programs. it goes without saying that all my clinic patients are vets.

i have been seeing CW for about two months now--this seems like an eternity in cancer time. CW has renal cancer, a fairly aggressive and difficult to treat disease. he has been to other cancer centers but is now seeing me for what he believes to be the best care available. his cancer has spread to his lungs and his brain. two weeks ago he had the tumor in his brain surgically removed. now he's in my clinic asking for more treatment, but i'm in the difficult position of telling him that the best care is really at FCC where all the clinical trials are based. i call one of my attendings who treats renal cancer at FCC. he is more than happy to accept the patient, but the VA hospital will not pay for the study at FCC.

"we have $800 in the bank," says his wife as her eyes tear up. "we are $25,00o in debt from his medical bills, already." CW tells me that they are going to cut down the trees on their property to sell for timber. they have nothing left. and CW is dying in front of me.

thus far, so early in my oncology training, my most difficult interactions have been with patients who are at the end of the line. i struggle with how to tell them they are dying while providing them hope at the same time. isn't this somewhat contradictory?

give hope, but prepare for death.

getting the gist of it

three months ago i began my training as a cancer doctor. i spend my days taking care of patients in varying stages of their disease. some waltz into my clinic with a smile and a new haircut. some are pushed in sagging, rusted wheelchairs. some appear only as death notices on my electronic patient record. all have needs.

taking care of the cancer patient is taking care of her entire family. taking care of the cancer patient is taking care of all her needs, whether or not they relate to her cancer because, at some point, all their needs relate to their cancer.

i worked hard to get to this point in my career. these are the patients i have always gravitated toward, but the more time i spend with them, the more drained i feel. to care of them, i must open myself to them and their pain. hopefully, in the coming days, months, years, i can chronical my interactions with patients, families, and health care workers as i begin to understand oncology.

i'm beginning to get the gist of it.