Time, part 1

There’s no good age to die.

Way too many of the patients I’ve seen over the past two years are harrowingly close to my own age. I think it’s less startling to hear that an older person has cancer than when a young person is diagnosed, but I have yet to identify the age when this transition happens.

Maybe it’s an unspoken understanding that older people die and younger people shouldn’t, but in the cancer community maybe age itself isn’t the best yardstick to decide who’s treated and who isn’t.

Last week in the outpatient clinics, I saw a man in his 80s with an advanced bile duct cancer. All cancers are varying degrees of awful, this type is more so than most. He had been on chemotherapy for a few months and had gone for a CT scan to see how the cancer was responding.

The attending with whom I saw the patient navigates patient care like an optimistic hurricane. He’s very smart and wakes up early so he can get some work done before he has to go start work, and then rushes home so he can do some work.  He does at least twice what’s expected of him because he loves it.

Sometimes his tie is a bit loose, and he may occasionally have a hair or two out of place. It’s the cost of productivity.

We went into the exam room to see if the patient had any new problems. Though frail and cane-supported, the clear-eyed man sat upright in his chair and spoke well. He was tidy and his hair was combed, his clothes were straight and fit well. He reported some weight loss but otherwise nothing new. The CT showed his cancer had grown. We told him this, and that it meant the chemotherapy wasn’t helping, which he had been expecting. That didn’t make it easier to hear.

It doesn’t matter how long past the average life expectancy someone lives, this conversation is never good. This man’s response was contained: he was (his words) ‘profoundly disappointed.’

The man slowly hitched himself up onto the exam table for a physical. My attending leaned over to put his stethoscope on the man’s chest, and the man took the knot of my attending’s tie in both hands. He tightened the tie a centimeter, and rotated it a few degrees so it was straight. It made my attending pause for a second and say, ‘oh, thanks.’

An incredibly warm gesture that repainted the tone of the room.

It was a tiny adjustment, but it was his nod to the order of life, a gesture more powerful than he could have spoken that he had values and cares and dignity. We finished the visit with a plan to switch chemotherapies because this is what he wanted to do.  His life would keep going.

With this cancer, a second-line chemotherapy may only help a centimeter, a few degrees of rotation. If they give this man one more day of good life, then maybe it’s worth doing anyway.