Last summer I met with a patient in my clinic who had come to the hospital with leg weakness and his CT scans showed widespread cancer. His type of cancer is rare and treatable with a pill which he had been taking for about a month. He was tolerating it without too much trouble.

During our first visit, he was insightful but overwhelmed. “I know how sick I am – just get me to December, that’s all I need.” He had a family milestone coming and told me he would be happy if he made it just one day beyond. Toward the end of the appointment, we reviewed everything and for the first time his emotions came through. “I don’t know what I did to deserve all this,” he said, meaning the weakness and the pain and the cancer in general. It wasn’t self-pity, it was honest confusion.

He made it to December. We celebrated with him and I started to look forward to his appointments as a highlight of my week. He told purposefully bad jokes and needled me every visit about not bringing him a danish and coffee. At the end of each half-hour he would say thank you and meant it.

A few months ago, we ordered a CT scan to check on how all of his different sites of cancer were responding, and one area was much bigger so we switched to a newer pill that hadn’t been available when we started his treatment. None of his symptoms had gotten significantly worse. A few weeks later I ordered another scan to see if the new pill was working and that same spot had grown much more. Not working. His lab work was starting to reflect it as well, so decisions about the next step in his treatment would need to be timely.

The next step was chemotherapy. Here’s the conflict with chemotherapy in patients with stage 4 cancer: most of the time, stage IV cancer is incurable. Just thinking and writing that sentence feels like I’m squashing hope for a thousand patients to come whom I haven’t even met yet. Maybe soon a treatment will be approved that will cure metastatic cancer, but today this happens almost never. So we give chemotherapy to prolong someone’s life as much as we can, but the trade off is choosing among nearly inevitable side effects. It can’t be a decision made without careful consideration.

I’ve already had more than one patient’s family member ask me if it’s ever worth going through chemo for metastatic cancer after their family member had passed away. Sometimes yes, sometimes no, is the best answer I’ve been able to come up with so far.

We talked about it and my patient wanted to go ahead and try it. We scheduled it for the next week but for a few different reasons we postponed for another week when he came back in. Over the weekend he got much sicker and died the following week, never having had the treatment.

He will always represent for me the cancer journey well traveled. It’s never a good road to walk, but he started off toward his self-ordained Promised Land and he was fortunate to have made it. When his disease progressed, he wasn’t bitter and he didn’t rage against the injustice of it. He got to where he wanted to go.

During our last visit, he said another thing. He had clearly been reflecting and had been thinking back to his months overseas in the service when he was young, on all the friends who weren’t fortunate enough to join him on the trip home, and he told me he felt like everything he had after that was a gift. His family, his job, his life.

Almost like he was saying that he didn’t know what he had done to deserve all this.

He died and I’ll miss him even though I never knew him in any capacity other than as my patient. I looked forward to seeing him because I knew I’d laugh at some point when I did, and because he didn’t fall into the trap of focusing on the injustice and inequity that advanced cancer sets for us.

He walked his road, and he made it to the end of it, and then he proudly and gratefully stopped walking.