For Ellen

“to live in this world

you must be able
to do three things
to love what is mortal;
to hold it

against your bones knowing
your own life depends on it;
and, when the time comes to let it go,
to let it go”
Mary Oliver, New and Selected Poems, Vol. 1

As a parent, you are not supposed to have a favorite child, and since some of us physicians feel a strange but kindred protectiveness for our patients, likewise we feel guilty about having favorites.  But we always do. My favorite patient died last night.  On my last day of work, I gave her my email address and my cell phone number, so we could keep in touch.  She gave me a bright red stuffed teddy bear, so that I would always remember my “wild red headed woman from Texas.”  Except that she had no hair–she had grown and lost it so many times over the six years I treated her that even I lost count.  When I retired, I made sure that she had a follow up with one of my colleagues, who I trusted would give her his best opinion and effort in managing her care.  When he saw her in March, he told her there was nothing more he could do.  She signed on to hospice the following week.

She was diagnosed with a rare form of cancer of the uterus nine and a half years ago.  By the time I met her, in 2008, she had already developed lung metastases and had undergone several courses of chemotherapy, none of which had kept the metastases in check for very long.  After a trial of radiofrequency ablation which resulted in a pneumothorax and chest tube, she was referred to me for consideration of stereotactic radiosurgery.  We treated her lung lesions one by one, and one by one they faded into scar tissue.  She was happy and relatively without symptoms until eighteen months ago, when she began to recur in the lung, and brain, and soft tissues of her muscles.  She remained upbeat, larger than life, encouraging the radiation therapists to treat each new lesion as it occurred.  My entire staff looked forward to treating her every time she returned to the department.  We joked about awarding her “frequent flyer miles” and she laughed and her blue eyes sparkled. Her chocolate chip cookies were legendary, and she gave us the recipe, but they never turned out the way they did when she baked them.  We accused her of leaving out a secret ingredient and she protested vigorously.  She said she would never do that.

She traveled a lot in the last year of her life—to visit her children, to see a new grandchild being born.  Her last trip was to New Orleans with her husband, where she looked forward to eating beignets and listening to Dixieland jazz, even though her trip was interrupted by an emergency room visit for shortness of breath. When we parted at the end of February, we promised to keep in touch and get together for lunch or dinner but she had complications from her last course of therapy, or from the cancer itself, and when I heard from her by text and by email, the news was not good.  In her last email, she told me she had joined a gym, determined to try to regain some of her strength. She promised to call when she was feeling better.

She did call me, last weekend, to see if I could have lunch with her and her husband on Thursday.  I missed her call, but I knew I was busy that day, so I called her back to reschedule but she did not pick up the cell phone.  And so I was not surprised when I received the news today that she had passed away last night.  Not surprised, and yet astounded, that such a vital life force had left us.  My entire staff is bereft.

In his email to me and I am sure, countless others who knew and cared about her, her husband included two photographs of her.  In the first one, they are cutting their wedding cake—she in her beautiful white dress with her long flowing red hair and he, handsome in his tuxedo and moustache.  Over thirty years must have passed between the first photo and the second, where she stands alone, healthy, beaming, and holding a yellow rose.  After all, she was from Texas. As I looked at the pictures again this evening, it occurred to me that I knew that the ingredient she poured into those chocolate chip cookies but forgot to write down for the rest of us was love.  Simply and purely, love.

Why I Don’t Go to Funerals

For Nick

Some things are just so damned hard to write about.  People often ask me, “Why do you have so many animals?”  The current count is 4 dogs, two horses and a cat.  I used to say, “Because it’s good for my children to learn responsibility.  Having a dog, whose life is so much shorter than our own, teaches them about love, and about death.  They get to PRACTICE parenthood, before it’s for real.”  The fact is, now my kids are grown.  My animals are for me.  They teach me about love, and acceptance, and courage, and stoicism and yes, about death.  But how can one ever prepare for the death of a child?  It shakes a person to the very core of his soul.  I don’t practice pediatric radiation oncology.  I am just not constitutionally suited for it.

So it was with remarkable dread two years ago, that I faced a consultation regarding the role of radiation therapy in a 25 year old man, who was the favorite nephew of one of my medical oncology colleagues.  This young man had been a student at college when he suddenly lost sight in one eye. Initially he was misdiagnosed as having had a retinal detachment.  Sadly, that was the result, and not the cause of the problem.  The real problem was that he had a malignant melanoma, a very aggressive skin cancer that sometimes arises from the back part of the eye.  By the time he was properly diagnosed, the disease had taken away all chance of preserving sight, and the eye was removed.  It was an extraordinarily difficult choice for a young man to make—his eye, or his life, but he chose life.  Or so he thought.

By the time I was asked to see him, about six months later, he had a different problem.  The cancer had spread to his spine, and he was in excruciating pain.  He had been on chemotherapy which had not halted the progression of the disease.  Although melanomas are not thought to be very responsive to radiation, it was felt to be the last resort to try to get the pain under control.  What I remember about that first meeting was his incredible demeanor,  his grace under pressure, his forebearance, and his calmness.  Here was a young man who already knew that he was going to die. If he was angry, I certainly couldn’t tell.   This young man had decided to fight.  And fight he did.

Fortunately, his spinal tumor responded to radiation and his pain abated.  Despite the brief respite, his disease progressed –in his liver, his lungs, his bones and his skin, inexorably, site after site.  His doctors tried experimental protocols, vaccines, immunotherapy, every conceivable treatment available.  And each successive treatment failed—one after another after another.

The last time I was asked to see him, it was for pain resulting from a massively enlarged liver, loaded with cancer.  My staff bent over backwards to make sure that he could be seen, planned and treated all in one session.  In a radiation therapy department, this requires the coordination of at least 7 or 8 people, from the secretary, to my nurse and me, to my physicists, and finally to my therapists on the linear accelerator.  Everyone wanted to help this boy.  Despite his discomfort, and the shortness of breath caused by the liver constricting his lung capacity, he apologized for inconveniencing so many people.  We treated him at the end of the day.  I was surprised in the end that we were able to treat him at all, since it was so difficult for him to lie down and to be still, despite the fact that he had lost the use of his legs a few weeks earlier and was confined to a wheelchair.  The plan was to give him a single palliative treatment of radiation then return him to hospice care.  But it was far too difficult for me to say goodbye.  Instead I said, “if you’re better next week, come back and we can give you another treatment.”  I did not say goodbye.  I never said goodbye.

That last treatment was Thursday October 27.  He died on Halloween, October 31, nearly a year ago.  His uncle, my colleague was kind enough to tell me that the last treatment helped him, even if only psychologically.  Until the day he died, he talked about coming back to see his friends in radiation therapy, and me.  He passed peacefully, surrounded by his friends and family.

Doctors are notoriously awful about dealing with death and dying.  The experts say it is because we do not like to admit defeat and we do not like to face our own mortality.  As a group, we detest funerals, and we do not typically go to funerals of our patients, particularly in the field of cancer medicine.  The day came that this young man’s memorial service was held, in a beautiful garden at a public park, on a lovely fall day.  There was not an open chair in the garden.  Every single physician who had cared for this boy was there, and every last one of us was crying.  Sometimes, we just cannot run away.

When I was sixteen years old, and in high school, my history class was shown 16mm footage of the liberation of the Nazi death camps by American soldiers at the end of World War II.  I saw the hollow eyes, and the starved bodies of the survivors, too numb to even react.  And bodies of the dead, piled beside the road.  I remember that grainy black and white footage like it was yesterday.  Because that was the day I began to question the existence of God.

I know that when people die, the survivors say, “He went to a better place.”  Or “This has served a higher purpose.”  But really, what do you say when a child dies a hideous death from cancer?  If there is a higher purpose, I would really truly like to have it explained to me.  My friends and acquaintances say to me frequently, “Isnt it SO hard to do what you do? “  Most of the time, it is not.  But sometimes it is.  This was the one that was the hardest of all.