Some poignant moments with patients take me by surprise.  I have had hundreds (thousands?) of difficult discussions with patients.  They are all difficult and unique, but sometimes they unexpectedly and without good explanation, catch me off guard.

I saw a long term patient with metastatic cancer who survived recent saddle PE despite a delay in anticoagulation.  Not many people have this kind of strength.  When I mentioned this fact, she shrugged it off.  I began caring for her about 10 years ago when her physician left the practice.  Instead of a difficult transition, she was grateful and over the years, I grew to enjoy her quirky view of the world that somehow managed to be both positive and cynical.  This had amplified during the last chaotic four years.

The CT scan that diagnosed the blood clot had also demonstrated stability of disease, which in her case, still left a significant burden of cancer.   Today, she also looked more frail and seemed more tired. We discussed what to do next.   She had already decided before she came in to put off therapy for a month, which included the Christmas holiday.  We talked about taking a break from chemotherapy.  She was adamant, even as she joked out loud to herself, “even if it will kill me.”  We discussed that actually, it might.  She was unmoved.

Most of her concern, though, was how her husband would carry on.  I asked if we should call him to be part of the visit, as visitors are not allowed during these difficult pandemic filled times.  She declined.  He was out on the Cancer Center grounds walking their dog.  He’s better off out there, she had said.  He had always had trouble discussing the emotional part of her health and cancer, but instead had spent the course of her illness focused on the details: CT findings, tumor measurements, blood counts.

“He will be alone soon. You and I both know that,” she told me with direct, steely blue eyes. “And he doesn’t even know how to start the washing machine.”  She had begun encouraging him to spend more time with some of his friends, so he would have those connections and relationships after she had gone.  She described reassuringly that one of his friends was a local physician assistant.  “He will need those,” she said, without a trace of sadness.  Her way of tying loose ends, preparing herself, as well as him.

The thing about cancer is, you often get some prep time.  Some people spend that time in fear, others in peace. Some want life whatever the physical toll; others choose a more quiet and gentle approach, even if it is shorter.  Still, others try to find that balance, that middle road of enough therapy to keep going, but not too much as to destroy that time.

She didn’t mention how to prepare her children or grandchildren.   Looking back, I remembered that she had spent the summer bringing her grandchildren to the ocean and teaching them how to swim.  It was something she enjoyed, and it was reasonably COVID safe.  Now, looking back, maybe she had started this preparation long before I realized. And I agree: the ocean, with children and grandchildren, has to be the best way of all.

Elizabeth Blanchard is a hematologist-oncologist.

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