On The Road Again

On the road again
Goin’ places that I’ve never been
Seein’ things that I may never see again,
And I can’t wait to get on the road again.  Willie Nelson

 

If someone had told me even ten years ago that I would retire young and become an itinerant radiation oncologist I would have thought he had lost his mind.  As the career medical director of community based cancer centers, I was used to running the show.  And as the saying goes, I ran a “tight ship.”  Consultations were performed and documented in a timely fashion, day of the request if the situation was urgent, or within a few days if not.  The patients were given time to think about their treatment, but simulations could be done the same day as the consultation, or as soon as the patient agreed to treatment, and the new start times were never more than a week away. Patients were seen every week, or more frequently if needed.  I had the best team of radiation therapists, physicists, nurses and front office people that anyone could ever ask for.  But in early 2014, I like to say I retired.  But the truth is, I quit.

Articles about physician burnout are legion, and I have avoided adding to that literature in this blog. The truth of the matter is that we, as radiation oncologists, are a very privileged group.  We are privy to the most intimate details of our patients’ lives; we practice in a highly technical and ever changing environment which challenges us to be constant and consistent learners; our hours are regular and we are very well paid as a medical specialty.  And most importantly, we cure cancer.  What could be better?  But after thirty years in the field, I was tired.  2013 was a terrible year for me—in December of 2012 I lost a close friend, Catherine, and then my little dog Jack, and then in January my mother, and shortly after that my work partner Dr. William Spanos, the best colleague and friend a physician could ever hope for.  And in between, some very beloved patients who I had followed and treated for years.  I was done.

But a calling is a calling, and somehow, between the enchanted mountains of New Mexico and the healing hours spent on horseback and with my dogs, and the otherworldly sunsets and the pleasures of growing a vegetable garden, I needed to get back to doing what I do best—helping cancer patients.  So here I am, a “locum tenens” radiation oncologist, working for an agency, going where I am needed, for a few days, or a few weeks at a time.  On Sunday night I “saddled up” the old Suburban and headed to Las Cruces, NM to provide a little relief to the solo practitioner stationed there.

Today I saw an elderly woman who had just been diagnosed with locally advanced and metastatic lung cancer.  Despite the effects of her disease—weight loss, shortness of breath and pain—I could see that she had been and still is a beautiful woman.  I can’t cure her—no one can.  But I could promise her that I could make her breathing a little easier, and relieve the painful metastases in her lumbar spine. As I sat with the patient and her husband, I knew with certainty that I no longer had to be “in charge” or command my own practice.  I knew that I could help her.  And I knew, beyond question, that I had begun to love my profession again. For that I am very grateful.

Another Dog, Same Breed, As Soon as Possible

“Hark to Beaumont. Softly, Beaumont, mon amy. Oyez à Beaumont the valiant. Swef, le douce Beaumont, swef, swef.” Beaumont licked his hand but could not wag his tail.”  T.H. White, “The Once and Future King”.
               For the past couple of years, my life has been pretty easy.  I spent last summer putting in a vegetable garden, and making improvements in the landscaping around my home.  In September I went back to work after a somewhat abbreviated bout of retirement, but just part time covering other radiation oncologists’ practices.  My two Scottish Deerhound sisters, Queen and Quicksilver were then approaching 7 years old, and were long past the destructive behavior so characteristic of the giant breeds in their youth. My little mixed breed rescue Yoda had never been a problem.
             On December 19, 2015 I upended my quiet comfortable life by getting a new puppy, a ten week old borzoi named Pibb.  Two weeks later, I compounded the chaos by acquiring a “brother” for him to play with, an eighteen week old Scottish deerhound puppy named Cole.  Despite a few misgivings and knowing full well what I was getting myself into, I went ahead with what I knew deep in my heart was a preemptive strike. Queen had been limping off and on, and despite my denial I knew that the proverbial “other shoe” had dropped.  Her chronic lameness worsened suddenly a few weeks ago and like her dam before her, she was diagnosed with osteosarcoma, a bone cancer common in her breed.
                  As a radiation oncologist for adults with cancer, my day to day ethical challenges are few. I do my very best to be sure that my patients understand their diseases, and the side effects, risks and benefits of treatment. As a devastated dog owner, the decision making process is not so simple. The tell tale X-rays resulted in a consultation with a board certified veterinary oncologist, where my husband and I sat and listened to our options. Amputation and chemotherapy, the standard of care, would give Queen a median survival of 9 months.  Untreated the disease progresses rapidly, often times resulting in a pathologic fracture. Pain control is also a problem, and pain can often be ameliorated by radiation therapy–my own specialty. Except in the rarest of cases, the disease is incurable because metastases are present, whether they can be detected or not.  All treatment is palliative.
               As we sat with the veterinary oncologist two weeks ago, contemplating our options, I remembered my friend and vet oncologist Dr. Greg Ogilvie saying, “The dog doesn’t look in the mirror and say, ‘Oh, I only have three legs.’ The dog only knows that the pain is gone.”  And we were told that dogs tolerate chemotherapy exceptionally well, much better than human beings.  So we sat and nodded and thought that perhaps our initial instinct, which was to provide comfort care only, might be wrong.  Who knows better than a cancer doctor how important it is to provide and maintain hope?  And so we wavered.
                 In her incomparable essay “Oyez a Beaumont”, Vicki Hearne describes what it was like to lose her Airedale Gunner when he fractured his pelvis from prostate cancer.  As a dog trainer, her advice to clients has never wavered:  ”Another dog, same breed, as soon as possible.”  And then she admits to us, that it was ten years between the death of Gunner and the purchase of a new Airedale pup.  She says, with feigned indifference as our hearts break, “That was as soon as I could get to it,what with one thing or another.”  I got to it a little sooner.
               Deerhounds are homebodies, and our Queen particularly so.  Carsick since puppyhood, trips are stressful for her, and the risk of fracture even getting such a large dog in and out of the car is significant. Outside the veterinary specialty hospital, in the cold light of day, we lifted her into the car and she fell immediately into a sound sleep because she knew she was going home-home to her sister, her humans, and even those pesky puppies. We knew then that home is where she will be for what remains of her life.  We love her and this, more than anything, is what we owe her.

How To Become A Cancer Doctor

Start with one excellent childhood experience—a loved one who is cured.

Add a generous helping of baseline optimism, a cup at least.  More is better.

Mix in well a half cup of ability to suspend disbelief.  And then, maybe a pinch more.

Add a teaspoon or two or even three of denial.  Pollyanna had it right.

 

Remember to include an ounce of prevention—

Worth a pound of cure, so they say.  Suspend a quart of judgement, or two.

Make sure the oven is preheated with family.  Children help sweeten the mix.

Add three pets, or more.  A dog to welcome you home.  Two cats to curl up with.

 

Believe, truly believe in the best of all outcomes.

“Everything is for the best in this best of all possible worlds.”  Voltaire knew.

A gallon of forgetfulness goes a long way to wash the silt of failure away.

When there is nothing else, pray. Or wish.  Or hope.  Or desire.

 

Ice the cake of sadness with a sweet coating of self-forgiveness.

And when that recipe fails, start again.  Be kind.  Your patients are waiting.

An Extraordinary Life

“Death, be not proud, though some have called thee

Mighty and dreadful, for thou art not so”—John Donne

On a Sunday in January, 2014, I opened the New York Times Opinion section and stumbled upon one of the most unusual essays I had ever read.  It was written by Dr. Paul Kalanithi, who at the time was a 36 year old neurosurgery resident at Stanford who had been battling metastatic lung cancer for eight months.  Here is a link to the essay, entitled “How Long Have I Got Left?”– http://www.nytimes.com/2014/01/25/opinion/sunday/how-long-have-i-got-left.html?_r=0    The author’s point was one well understood by cancer patients everywhere—if the doctors could not tell him whether he had a month, or a year, or ten years, how could he possibly determine what his priorities should be and how best to live his life?  Should he finish his residency?  Should he write a book?  Should he have a child?  In his worst moments he wrote that he fell back on his first love—literature.  In the last sentence of Samuel Beckett’s The Unnamable, Kalanithi found a mantra to live by: “I can’t go on.  I’ll go on.”

As it turned out, he did not have long.  Despite the optimistic and sometimes humorous tone of the essay, Dr. Paul Kalanithi died of his lung cancer 14 months later.  But not without first doing ALL of the things he mentioned in the essay.  He finished his neurosurgery residency as chief resident. He repaired a fractured marriage.  He had a child.  And to our great benefit, he wrote a book called “When Breath Becomes Air” published posthumously in January of this year—a book which despite my oft stated incredible reluctance to read anything I know will make me cry, I grabbed off the shelf the minute I spotted it in a local bookstore.   I was not disappointed, and yes, I cried.

The courage of cancer patients, and of all patients facing life threatening disease astounds and inspires me.  Many go through grueling and exhausting treatments and manage to put one foot in front of the other—they “can’t go on…they go on.”   Paul Kalanithi not only went on…he wrote about his experience in a book that will stand not only as a cancer memoir, but as a profound piece of writing.  When faced with dying, he chose life by completing his training, by having a child, by believing every day that he still had much to offer.  In an essay for Stanford Medicine he wrote words for his infant daughter which were included in his book: “When you come to one of the many moments in life when you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more, but rests, satisfied. In this time, right now, that is an enormous thing.”

I hope you get a chance to read his book.  Even if it makes you cry.

In Praise of Angelina

I have always been one of Angelina Jolie’s biggest fans.  The Academy of Motion Picture Arts and Sciences saw fit to reward her 1999 performance in “Girl Interrupted” with an Oscar, but I wasn’t well and truly smitten until the second Lara Croft Tombraider movie was released in 2003.  In that film, Jolie, who performs her own stunts, is seen galloping on a dark horse while spinning a heavy shotgun from side to side to shoot alternating targets.  And she is riding SIDESADDLE.  If you don’t believe this, have a look here:  https://www.youtube.com/watch?v=tz1lCcs9tac  In the Lara Croft movies, she is the epitome of a strong, athletic, intelligent and self assured woman.  It may not seem like much, but I granted Miss Jolie a high honor indeed—in 2004 I named a dark, agile and fast deerhound puppy after her, the soon to be champion Caerwicce’s Lady Croft, aka “Angelina”.

 

In the years that followed the Lara Croft movies, Angelina Jolie went on to surprise her public in more ways than one.  The girl who initially achieved notoriety for wearing a vial of her second husband Billy Bob Thornton’s blood gained a different type of fame when she adopted a Cambodian child, and subsequently became a respected ambassador for the United Nations.  She has become well known for her humanitarian efforts, devoting as much time to improving the lives of refugee children as she does to her own career.  Recently, she has added the titles of author, director, and Mrs. Brad Pitt to an already impressive resume.

 

But perhaps the biggest surprise of all came two years ago, when she went public in the New York Times with the revelation that she is positive for the breast cancer gene BRCA1. In a moving statement, she wrote of her difficult decision, at age 37, to undergo bilateral prophylactic mastectomies and reconstructive surgeries in the hope of staving off the cancers that took her mother, her grandmother and her aunt.  She was clear and concise, reasonable and dispassionate in her account.   Not only did she raise awareness of the heritable form of breast cancer, she gave courage to all women facing the challenge of a mastectomy.  If one of the worlds most beautiful and sexy women could undergo such surgery in the glare of the celebrity spotlight and come out looking stronger and even more beautiful, so could some of the rest of us.

 

Today she has done it again.  In a New York Times article entitled “Diary of a Surgery” (http://www.nytimes.com/2015/03/24/opinion/angelina-jolie-pitt-diary-of-a-surgery.html?ref=opinion&_r=0 ), she reveals that she has recently undergone removal of her ovaries and fallopian tubes to prevent ovarian cancer, the disease that killed her mother.  She describes precisely the terror she felt when informed that some recent blood tests were equivocal, the dreadful anticipation of the results of a PET/CT scan and the realization that now, at age 39, she has entered menopause.  But she also describes the relief she felt once she had made a decision to go ahead with the preventive surgery: “I know my children will never have to say, ‘Mom died of ovarian cancer’.”

There’s bravery and then there’s true courage and grit.  It’s one thing to perform gymnastics while swinging from the rafters of the Croft estate, or to shoot a rifle off the back of a galloping horse.  It’s quite another to write clearly and objectively the story of being diagnosed with a genetic mutation, and of the careful informed decisions she made to minimize her risks, while at the same time admitting that her decisions were not necessarily the right ones for everyone.  As Angelina says, “Knowledge is power.”  We owe her thanks for sharing hers with us.

 

The Curbside Consultation

Recently a friend of my husband’s in San Diego had a mammogram which showed some suspicious microcalcifications in her right breast.  She underwent a stereotactic biopsy which revealed ductal carcinoma in situ, the earliest form of breast cancer also known as Stage 0 breast cancer.  This type of cancer is non-invasive and does not metastasize, however, if untreated it can progress or recur as a more serious type of breast cancer, so at the very least excision of the abnormal area is indicated, and in some cases radiation and/or mastectomy are necessary.  My husband asked if I would speak to her regarding her breast cancer, and somewhat reluctantly I said yes.

 

Why reluctantly, you might ask.  Isn’t that the nice thing to do?  I said to my husband, “I think it’s a mistake to do consultations over the phone.  I have no access to the mammograms or pathology report, and I cannot examine her.  These things are important to have and do to give someone an informed opinion about her case.”  He said, “But can’t you just talk to her a little bit and recommend a surgeon, and maybe give her a bit of information about radiation therapy?”  I agreed to do it.  A few days later we connected by phone.

 

Having practiced in San Diego for twenty one years, and having a major interest in breast cancer, I know every surgeon in San Diego and Riverside counties who specializes in breast cancer.  Likewise, every radiation oncologist and medical oncologist.  I am a virtual referral encyclopedia—tell me where you live and I will tell you where to go.   In this case I recommended the surgeon whom I would choose to operate on ME, if I had breast cancer.  Same thing for radiation oncology.  I did this for my husband’s friend, and we discussed her case at length.  Because of her relatively young age, excision alone was a bad choice, so we discussed the pros and cons of excision plus radiation versus simple mastectomy with or without reconstruction.  At the end of the conversation she thanked me, and then mentioned that there were actually TWO areas in the breast that were biopsied and were positive, and they were not particularly close together.

 

That little fact, which I would have known if I had had her pathology report and her mammograms in front of me, changes everything.  If a woman has multifocal disease, there is a good probability that she may be better off removing the breast.   I backtracked and covered that point, but I worried that I had made an anxiety provoking situation much worse by confusing a new breast cancer patient.  In the end, she sought the care of an excellent breast cancer surgeon, and I know she will be fine.  But I have the lingering feeling that in trying to do the nice thing, I did the wrong thing.

 

Think of this when you stop your doctor friend on the street to ask about a friend or relative who has recently been diagnosed with cancer.  Curbside consultations do no one any favors.  If you or a friend or relative need an opinion, get an INFORMED opinion—present to the consulting physician with your history, your radiology, your lab work, your pathology and your body to be examined.  Then, and only then, you will be assured that the recommendations that you receive are the ones you should truly follow.  It could save your life.

Siskel and Ebert

I have always loved the movies.  Like every grade school kid watching reruns, I cried when Bambi’s mother died, and when starry eyed Judy Garland clicked her heels and said, “There’s no place like home!”  But when the big budget films hit the screen in my early pre-teen years—Ben Hur, Camelot and Lawrence of Arabia, I was irretrievably hooked.  Sitting in a dark theater, I could escape from actual or imagined troubles.  Some people prefer live theater, but for me it was always the big screen, where I could pretend to be Guinevere as Lancelot leaned in for a kiss, or Holly Golightly, or Cleopatra, up close, more real than in real life.  By high school I was reading the film critic’s reviews in our local paper, and by college I had my favorites.  Pauline Kael was far too esoteric for me—my “go to guys” were Gene Siskel and Roger Ebert with their trademark “thumbs up” or “thumbs down.”

I was channel surfing last night and I just happened upon CNN which was airing a documentary film about Roger Ebert, his career and his struggle with cancer called “Life Itself” from his memoir of the same title.  I had been aware that Ebert had been battling head and neck cancer for years before his death but I was not well versed in the details of his illness.  Roger Ebert was diagnosed with papillary carcinoma of the thyroid in 2002, typically a rather low grade cancer treated primarily with surgery. Unfortunately he was unlucky and the cancer recurred, ultimately necessitating removal of his lower jaw with subsequent loss of his larynx, and his ability to speak and swallow.  What was unique about Mr. Ebert was that unlike many public figures, especially those in the visual media whose jobs sometimes depend on facial appearances, he chose not only to go public with his illness, but to ENGAGE his many fans and followers in his day to day struggles via his website, his blog, and his Twitter account.  He allowed Steve James, the documentary filmmaker, to film him not only on his best days, but also on his worst.  He smiled and joked for the camera nearly immediately after his radical mandibulectomy and neck dissections, even as he was being suctioned for the secretions which if left untended would choke him.  His wife Chaz, his stepchildren and grandchildren were equally generous, at a time when the family was undergoing much pain and hardship.  He clearly had his demons and his days where he wanted to quit, but ultimately he was buoyed by the support he received from not only his fans, but from directors and actors he had at times panned.  To see Martin Scorcese pause to wipe a tear on camera when discussing his friend was a window into what this person meant to his friends and peers.

What I had forgotten, and was reminded of while watching the documentary, was that Ebert was not the only member of the Siskel and Ebert team who suffered from cancer.   Gene Siskel was operated on for glioblastoma, a malignant brain tumor, in the spring of 1998.  Only his wife knew of the diagnosis—he chose not to even tell his children.  He was back at work nearly immediately, and only when he became symptomatic again in early 2009, did he request a leave of absence from his show.  He died of complications of a second surgery to deal with recurrence in February 1999.  His friend and colleague Roger Ebert only learned the truth about the disease on a Friday, just days before he died, and had planned to see him on Monday.  Siskel died that weekend.  Ebert and his wife were devastated that they had not known, and had not been able to convey the love that was in their hearts.  I can only imagine how his other friends and family felt.

In my career, I have seen it both ways.   I have had patients who have their entire families with them for each treatment, who have written books about their illness, who have blogged about it, who have made public appearances and who have been pillars of support groups.   I have also had patients who were absolutely adamant that no one, sometimes not even spouses or children, should know about their cancer and treatment.  The reasons have been many—fear of unemployment, fear of upsetting loved ones, fear of being seen as weak or ill, and in one case, a minister who feared that his congregation would see his illness as punishment for prior sins.  But the common denominator was always one thing:  fear.

My patients generally have made up their own minds about what to reveal and to whom.  I respect their decisions and support them in whatever way that I can.  But when they do ask me, I always tell them that it is better not to take this particular journey alone.  Not every movie has a well-executed plot or a happy ending.  But as Siskel and Ebert would always say, there is joy in the characters you meet and love along the way.

Do Dogs Know They are Dying?

Labor Day, 2006, is a day I will never forget.  It was a gorgeous day here in San Diego—bright, sunny and nearly 90 degrees.  I decided it was a perfect day to give the dogs an outdoor bath.  At the time, we had Valentine, the matriarch at nearly twelve years old, Izzy who was four, and the two young  ones Magic and Angelina who were two years old.  We started with Valentine—at her age she’d had a little problem with urinary incontinence, and she needed her bath the most.  We knew that the coiled up hose sitting in the sun on that hot afternoon had enough warm water to bathe her in, so my daughter and I mixed shampoo in a bucket of hot water from the kitchen sink, and just outside the garage, we soaped her up.  She seemed to be enjoying herself, a nice soapy massage on a beautiful day, and then a quick rinse.  As I turned to get the towel to dry her, I heard my daughter say loudly and in a panic, “VAL, DON’T FALL DOWN!”  I turned back around and she was gone, down on the wet pavement, eyes blank.  She never felt a thing.   I spent the rest of the afternoon sitting on the driveway with my dead dog, brushing her hair until it dried and the crematorium people came to take her away.  Needless to say, no one else got a bath that day.

I once read an essay by an oncologist who said that she hoped that she would die of cancer.   I was baffled by this, because my personal preference would be to go suddenly, of a heart attack or a massive stroke, preferably while doing something I enjoy.  But her reasoning was quite clear:  she said that with cancer, when you know that your days on earth are numbered, you still have time—time to do the things you always wanted to do, time to say good bye, time to make amends.  This has actually been true for most of my patients—when they know that they are diagnosed with a life threatening illness, their priorities change.  If they have the means, they live the lives they always wanted to live, for as long as they are able.  They remember, they forgive and they forget.  The trivialities of daily life become unimportant, except insofar as they struggle to get through them.   Many become the person they always wanted to be, and I hope that if this is my fate, I have the grace to do the same.

Today we took old Magic to the veterinary cardiologist.  Magic is my eldest deerhound—a big male at 120 pounds, and nearly ten years old.  The last two weeks have been hard for him—we’ve had thunderstorms and he has always been afraid of thunder.  In desperation over his anxiety last week I called his vet for a prescription for a tranquilizer.  It worked temporarily, but on Tuesday we had strangers in the house and he was panting, salivating, and his heart was beating far too rapidly.  I laid a hand on his chest and I knew instantly that his big old heart was failing.  Today the diagnostic echocardiogram confirmed what I already knew—that my big guy has dilated cardiomyopathy, and that he is in congestive heart failure.  We started medication immediately, and I am hoping for a few more weeks, or a few more months with this grand old man who is, as my husband says, “the dog who never did anything wrong.”

Do dogs, like humans, know when they are dying?  I don’t think so.  And in fact, for their sake, I hope not.  Unlike us, they have nothing to apologize for, and perhaps their next meal, or a walk in the park, or in a dream a wild chase after a highland stag, followed by a soft bed and the touch of a human hand is all that they hope for and dream about.  As Magic slowly made his way out of the van today onto solid ground, he was greeted warmly by Queen, Quicksilver and little Yoda.  I can no longer promise him a life beyond his years, but I promised him today that every day from now on will be the best day I can give him—lots of treats, a comfortable place to rest, and with all certainty, no more baths.

Stuart Scott’s Acceptance Speech

Sometimes I feel like what I have to say isn’t very important and after watching a video clip of Stuart Scott accepting the Jimmy V Award for Perseverance tonight on ESPN, I think you might prefer to hear from him.  Background:  Stuart Scott was diagnosed with cancer of the appendix in 2007 and has been battling the disease for seven years.  Jimmy V, or Jimmy Valvano was the head basketball coach at North Carolina State, who died in 1993 of cancer but was known both in sports and his personal life for his slogan “Don’t give up, don’t ever give up.”  According to Wikipedia, Jimmy V’s tombstone reads, “Take time every day to laugh, to think, to cry.”

If you have time, continue to watch this video to see the clip about Scott’s enrollment in a clinical trial at Johns Hopkins, and then just as amazing, Michael Sam’s emotional speech about tolerance, acceptance and growing up “different” as he accepts the Arthur Ashe Courage Award.  These two guys say it all, so please watch:  http://espn.go.com/video/clip?id=11225895

More about my experiences in Dermatology tomorrow.

Love and Loyalty From the Souls of Dogs

“Such sadness and endearing and abiding love…”  Fran

I am by nature a “right brain” person—despite my training in science and medicine, I prefer paintings and photographs to words and mathematical constructs.  Over the past two years of writing this blog, I have resisted on many occasions the urge to add pictures to this website, despite the fact that I possess wonderful photographs of the things that I write about—my family, my dogs, my horses and my patients.  I am constantly taking pictures—I have chronicled my entire life in photographs from my first Kodak Brownie and I will continue to do so.  But I started writing again, thirty eight years after graduating from college with an English degree, to see if I could “describe” rather than “illustrate” the events in my life which have had an impact.  I want to write stories that leave a little bit to the imagination, to my readers’ right brains—stories that can be read out loud.

For the past few months I have been following the saga of Roo on Facebook.  Roo is an Ibizan hound owned by the artist Nan Kilgore Little. Affectionately known by their owners as “beezers”, this breed’s history dates back 5,000 years to the times of the Egyptian pharaohs.  The erect ears and tall lean bodies of these hounds are depicted in hieroglyphs in the tombs of Ptolemy, Nefermat, Mereku and Tutankhamen.  Think of the god Anubis, Protector of the Dead, and you will have a good visual image of the head of this hound.  Brought to the Balearic Islands off the coast of Spain by the Phoenicians in 800 B.C., these dogs have hunted to put food on the table of their masters for centuries.

Roo turned sixteen years old a few weeks ago, an extraordinary old age for a large sighthound. You can see it in the pictures—the eyes, once keen are now cloudy and the strongly muscled hindquarters have wasted.  The bone structure appears more prominent, and yet more delicate at the same time. The ears are nearly transparent, and beautifully veined.  Nan started to post pictures of him on his daily walks, interacting with the other dogs in the household, and resting on his favorite pillow—pictures which have inspired a legion of Facebook followers who clearly feel privileged to watch the “old man” in his waning days and to take that last journey with him and his loving family.

The last forty-eight hours have been tough. Old Roo, with his brightly colored bandanna and his watchful countenance has stopped eating and has taken to his bed, his head resting on his favorite pillow.  He is not in pain, but he is very tired.  No more walking in the Wild Yard and no more jumping over the Big Tree.  His best friend, an Australian cattle dog named Barkool, has taken up watch and rarely leaves his side.  Barkool is neither elegant, nor particularly beautiful and his squat body is a contrast to the lean and classical Ibizan.  He is Sancho Panza to Roo’s Don Quixote.  He is the friend we wish we all had.

My Facebook friends love dogs as do Nan’s and as a result, we frequently feel compelled to put up photographs of abused, starving and abandoned canines in need of rescue, or dogs beaten and bloodied in the service of man’s cruelest whims.  But rarely, in these hastily posted pictures, we see a glimpse of life as it can and should be.  Yesterday Nan posted a photograph of Roo and Barkool.  Roo is wearing his blue bandana and is wrapped the cocoon of his softest blanket, one covered by multicolored hearts.  Barkool’s head is tucked under Roo’s chin as a pillow and his stocky body is still as can be.  His eyes show apprehension, and resignation at the same time.  He is, above all, present for his buddy.

Sometimes friends and families of my patients are uncomfortable visiting their loved ones after a diagnosis of cancer, or even more so at the end of life.  They ask me, “What should I say?” or “What can I do?” The answer is revealed in Nan’s picture of Roo and Barkool:  without fanfare, without words, without tears, just be there.