I am often struck that those I work with who have enormous reasons to be depressed — they may be poor, physically ill, uneducated, and very crazy — are not depressed, not at least as I describe depression, a state of melancholy and dejection. In my view, there is a terrible, terrible hopelessness in these situations and in these lives. And then, there is William Jenkins.
With William, I find I begin to get depressed myself at the very thought of transporting him again to another of those many medical appointments he has, and I am, as his social worker (case manager) responsible to take him there. This depressed feeling that comes over me sometimes doesn’t leave for days. I have accompanied William on his trips for a colonoscopy, several CT scans, eye doctor appointments, and foot doctor appointments. He is obese, diabetic, and he has an aneurysm, and on and on from there.
William is diagnosed mentally as having schizophrenia, paranoid type, and he takes the strongest anti-psychotic medicine there is, clozapine. He is sixty-seven years old, and there are many days when he does not know if he is on foot or on horseback. He very easily becomes confused. You must say everything to him twice. He is a short, stout, white-haired man, unsteady on his feet, and as I’ve said, his physical ailments seem to dwarf his mental problems. In spite of all of this, he is not gloomy, but is very pleasant and grateful for whatever he gets in the way of services, and he gets a lot. And now this, the latest diagnosis for William, lung cancer.
I have known of this for a week. I have seen the lab results of his biopsy, and spoken to one of his doctors. I am sure he does not understand what a biopsy is for. I have seen him several times since getting the results, but I have not told him. His doctor will tell him on Friday. Of course, I will be there when he gets the news because I go everywhere Bill goes. There is hardly a soul in the world who will take him even across the street, in spite of several grown children and other relatives in the area. So this becomes my job. Well, sort of my job. Technically speaking, I am a social worker for his psychiatric ailments, which are considerable, as I’ve noted, except it seldom works that way. Whatever needs to be done, we do it, or it does not happen. Bill Jenkins is a good example of this.
I try some days to figure out why Bill makes me feel so gloomy, so low. He is not at all difficult, and in our psychiatric world, that means he doesn’t act out, scream and generally misbehave when you take him someplace. He is not at all like that. As I have said already, he is grateful, and expresses his gratitude often, even if he mumbles, and my hearing is not what it once was, so I don’t get what he says half the time. After about four hours of this mumbling, often incoherent, meaningless speech, one grows pretty weary.
Bill’s medical appointments seem endless. We go in for one thing, and two or three more tests are added on. And always, the medical people want another sample of his blood, but he has no reachable veins in his arms or anywhere else. So we wait for the best sticker the facility can find to draw blood. It is like getting blood out of a turnip. I have taken him to major hospitals in the area, trauma centers for a CT scan that requires an IV (a contrasting image, they call it), only to have a nurse or tech come out and tell me that they just can’t get an IV in Mr. Jenkins, and so they are giving Bill a scan that does not require an IV, and of course the scan they give him is less revealing, and we might be back a week later to try to get the real thing.
So a new order gets written for a CT scan with contrasting focus or something like that. The costs have to be staggering, but with Medicaid and Medicare, Bill knows nothing of such costs. He hasn’t for years, maybe his entire life. All of this can be frustrating, of course, but I know what puts me on edge so often with Bill is how close I am to his age. He is sixty-seven and I am sixty-three. I know I am lucky not to be him, and I know as well that he has for years abused himself something fierce.
For many years, Bill was a down-in-the-gutter drunk, and no doubt a drug user. Did I mention he also has hepatitis? But all of that was at least twenty years ago or more, and hard as it is for me to understand why, Bill very much wants to live to be ninety. Or older. He told me that one day. Yet, for some reason, something he told me early one morning as he awaited a colonoscopy, I think it was, sticks in my mind like putty. He said, “You know Ray, I have a great life! I really do.”
And then he grinned his false teeth grin, and all I could think of was, Here is this poor soul (my designation) who lives alone, with what family he has seldom coming around, unless to take advantage of him — he has a thirty-four-year-old son who visits and steals his money — and yet he feels he has a great life. His only activity that I know of, and I know much about him, is to come to our mental health center for a few hours on Tuesday, Wednesday and Thursday each week, and then home to his tiny apartment in the Portland section of the city to be alone with the TV until the following Tuesday. Then it is back to our clinic. That’s it. That’s his great life!
Well, I know this much. When I take him to the doctor later this week, his life is about to get a whole lot less great. But when Friday arrives and he gets the news, something I have been dreading to witness, he says flatly that he does not believe he has cancer. He feels too well to have cancer. Then he says the cancer doctor he has been told he will soon see (with me there, of course) will be the one to decide whether he has cancer or not.
And so this compassionate woman doctor, born in Cairo, Egypt, I think it is, Dr. Telepolni, repeats the diagnosis for Bill. I figure I understand what is going on in Bill’s muddled mind. This doctor is all right for a woman, for the usual things, I imagine Bill thinking. And a foreign woman at that. But cancer, what can she know about cancer? She is now telling him the results of the biopsy. But all he hears is the word “cancer.” Where it is located doesn’t seem to get through to him. Or maybe cancer is cancer, and it is to his mind fatal, no matter where it shows up. And maybe he is more right than wrong.
Dr. Telepolni repeats herself. “No, Bill. They are sure you have lung cancer, but they don’t know yet how involved it is.” I am quite certain Bill does not know what is meant by the word “involved.” I don’t offer any clarification, although I could. Let it go, I think. He knows he has cancer, despite his denial, but his mind has designed a way to cushion the bad news, and that is fine with me. He understands pretty well, though, and he will brood later when he is alone.
Before bringing him to this appointment, I called his ex-wife, with whom he has something of a relationship, and against all the rules of confidentiality, I tell her the news. I am not supposed to do this, not without his consent, but I do it anyway in the hopes that she might be there to meet him at his apartment when I take him home so that he is not alone with this diagnosis. I don’t want to just drop him off after such news. She says if she can be there, she will, but she isn’t there when I get him home.
I have to leave him alone or take him home with me. Some option. I leave him, but first I stop at the complex’s administrative offices and talk to Pam, the manager, a thin, rather unhealthy-looking redhead in her forties. I explain the situation, again violating Bill’s rights of confidentiality in the interest of getting for him some company and comfort after a tough day. Pam has known Mr. Jenkins, as she calls him, for fifteen years. I can see concern in her face as I relate the story, but also there seems to be excitement at hearing the news. It is almost as if it is terrible news for Mr. Jenkins, which it clearly is, but isn’t it wonderful it is not happening to me? Then I tell this woman Bill has lung cancer. Her excitement abates and I notice she crushes out the cigarette she is smoking.
“I thought you were going to say he had prostate cancer. I didn’t know him to smoke.”
“No, he doesn’t smoke now, but he did for twenty-five years. He hasn’t smoked in twenty years,” I tell her. That is the truth.
I know Pam, and a man by the name of John who has come in during the conversation, will go and visit with Bill and sympathize with him, probably giving him more attention than he has had in years. Maybe even his ex-wife will show up. In any case, I’ve done what I can think of for the moment in what is obviously not an easy situation.
The next week when I see Bill at the center he acts no differently than usual, except to tell me how great he feels, even bragging about his recent weight loss. He does not connect it with the disease. It is as if he hasn’t been told the news, but of course he has, and I know he knows. But now I sense a bit of embarrassment creeping in for Bill. We don’t talk about cancer, except I have to remind him I must take him in a few days to the cancer center where he has an appointment with the specialist, Dr. Denton.
When that day comes, Dr. Denton tells Bill, as if the doctor at Portland Clinic had not done so before, “I am sorry, Mr. Jenkins, but you have lung cancer. We don’t know yet how involved” (or maybe he said “invasive”) “it is.” He talks of two spots, but because the non-contrasting CT scan taken weeks before is unclear, Bill will have to have still another done. The doctor calls this scan a “PET scan.”
“Too bad they didn’t get it right the first time,” I mutter, but Dr. Denton ignores me. I tell him too how they couldn’t get in an IV and settled for a lesser image. Again, he says nothing. He tells Bill that if there is only one area involved, surgery is possible (likely), but if more lung is diseased, surgery is not a possibility. He doesn’t say what is.
Bill understands a bit of this conversation. He knows the word “surgery.” “Cutting,” he calls it, but he will allow them to cut on him if he can survive. I know that without asking him. I worry a bit that they will likely pump Bill full of a lot of medicine that will have him very ill all the time, and the result is the same, only he gets a few more months to live. But when you have insurance, such as Bill has, you get treated. Those machines cost too much to sit idle. Bill for his part accepts now that he has cancer — it has come from a specialist, who is also a man — but what that means, well, that still is not very clear to him. As far as I am concerned, that is not so bad a result. All this you- must-know-everything honesty at all costs crap is exaggerated as to its worth.
No, a little muddiness isn’t half bad, as far as I am concerned.
Raymond Abbott is a social worker.