Missed opportunities give leverage to cancer

Last week a patient said to me, “You live your whole life thinking you’re going to have time to enjoy life later on, and then this happens.” Then he started to cry because we had just reviewed his recent CT scans and some of his lab results and he had a new diagnosis of a type and stage of cancer that meant he likely had about eight months to live. Treatment might give him another three.

Two weeks and one day before this, he had no symptoms.  The next day he left a social event early because he had indigestion.  Then his skin started to turn yellow.  Then he got yellower and his eyes also turned yellow so he made an appointment with his primary care doctor which led to labs and CT scans and a biopsy and here we were.

You live your whole life thinking you’re going to have time to enjoy your life later on. Off the top of my head I can think of three patients who voiced this same lamentation at some point since I started fellowship. This man wasn’t giving me advice; he wasn’t warning me of anything.  He was wiping his eyes and speaking into nowhere at nobody.

I felt like it might not be the best time to ask him what he’d have done differently but, man, did I want to.

In general, I object to carpe diem sentimentality because its evocation mostly just makes me feel guilty when I’m not out having transcendent life experiences. Since Dead Poet’s Society hit theaters, I’ve heard it frequently enough by this point that it almost seems dismissive of people’s suffering now.

I sat with the man a little while and we came up with a plan (we had other things to fix before we could even think about chemotherapy).  Then I left the hospital and drove around for a while.

One thing that’s really wonderful about being an oncologist is the relationships with patients tend to be very genuine, and patients often take the opportunity to have a meaningful conversation. I’ve had many talks over the years about really profound stuff, and more than a few of them were about what makes life meaningful. The prospect of imminent death tends to clarify this for people.

Once, I met a champion free diver with leukemia whose only regret was that he didn’t take better care of his teeth (could I possibly have made that up?). I was an intern on overnights when his blood pressure dropped because he finally developed an infection his failing immune system couldn’t handle.  I went to his room to talk to him about how aggressively he wanted us to treat the infection this time, and through clenched teeth but smiling lips he calmly asked me not to transfer him to the ICU and by morning he was gone.

Some patients aren’t quite as unburdened:  The misery of advanced cancer compounded by the emotional anguish of regret, or words unsaid, or missed opportunity is a very hard thing to witness, and gives the disease leverage it shouldn’t be afforded.

I’ve consolidated what I’ve gleaned to these:

1. Pay attention. Sometimes “you live your whole life thinking you’re going to have time to enjoy your life later on” means “you were so focused on what might be better someday that you missed what was actually happening.” Forgive me for stealing a line from somewhere, but you can’t buy happiness with unhappiness.  I don’t remember where I heard it.  Some hardships we endure because they’re worth it (ask anyone who has been woken up every 45 minutes by a newborn baby), but I wonder if we subject ourselves to some hardships because we’re convinced that we’re buying an equal measure of goodness in the future? I know I could be much better at indulging in some simple joy right now, because the thing about the future: we never actually get there.

2.  Move. It’s possible this is my own bias, but my impression is that patients who navigate advanced cancer more comfortably are folks who were more physically fit before they got sick.  It may be circular logic, but I also think these were people who got out and did stuff.  I don’t think free diving is mandatory, but moving around a little is better than not moving around a little, if you’re able.

3. Sit still. Some of the best conversations I’ve had with end-stage patients were with people who intentionally took time to reflect on their lives. I suspect they were also reflective people before they got sick.  Some folks wrote things down (I’ve known a few patients with their own blogs), some found gratification in corresponding with family and friends, and for some it was enough to sit in a chair and look out a sunny window. The contemplative process took some of the victimization of cancer away, and gave the patients some power back.

4. Forgive something. A women I was seeing regularly in a clinic I visited this year has stage four cancer and is constantly in some degree of pain.  When we’d get past the medical part of the visit and into the chatting part, she would bring up how angry she was with one of her family members because of years of unresolved conflict.  When this came up, it was obvious that worse physical pain would wash over her and it was hard to watch.  Resentment is a burden we carry that hurts us, and usually doesn’t affect whatever or whomever we resent. Sometimes we resent ourselves for things we did, choices we made or didn’t make.  The cost is more than emotional: It manifests in our bodies, and it costs too much.

5. Let go of fear. The patients I’ve watched live well with end-stage cancer have somehow conquered their fear. It’s not that they were unafraid, but they managed to assimilate dealing with symptoms, and disease progression, and eventual death into the process of living their remaining days. Fear doesn’t achieve anything, but it’s well capable of physically draining us and yanking us out of the present into a possibly fictitious future.  It’s another facet of the same mistake made by my newly-diagnosed patient.

Like I said, I didn’t have the chance to explore any of this with the man. The fact that this was one of the first sentences he spoke after learning life altering news makes me suspect that his personally held values came into a new clarification for him. It must be terrible to find a mismatch between the life you lived, and the life you wished you had lived.

Frankl has a suggestion for us, which I like:  “Live as if you were living already for the second time and as if you had acted the first time as wrongly as you are about to act now!”

Not everyone gets the opportunity.

Kenneth D. Bishop is a hematology-oncology fellow who blogs at Out Living.

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