A Dish Of Love

I met a most wonderful eighty-nine-year-old woman last week.  She came to see me for her newly diagnosed stage four rectal cancer.  She is dying from her cancer.

Her cancer is an unusual rectal cancer. The most common type of rectal cancer is called adenocarcinoma.  This woman’s cancer was different and of neuroendocrine origin; neuroendocrine cancers of the bowel are rare in comparison to adenocarcinoma.  These cancers have a propensity to grow and spread very fast.  They often spread to the liver and use it as a fertile garden to grow in.  This was the case with the woman I found sitting across from me at the end of January.  Her liver was packed with cancer.

The type of cancer people have is usually determined by the way it looks under the microscope from tissue that is taken via a biopsy or surgery. Pathology doctors make these diagnoses.  The oncology team members who work in the laboratory to make these diagnoses are often unrecognized, yet they are so important; their work is the foundation of much of what I tell a patient about treatment recommendations and prognosis.  If you ever get a chance to thank a pathologist or laboratory technician, please do.

Accompanying this woman to her visit was a son.  Her other three children, two daughters and another son, were conference calling into the examination room.  They all would have been present in person but hospital policy with the ongoing Covid pandemic only allows for one loved one to enter the hospital with a patient.

Upon review of her case prior to seeing her, I noted she had recently had a geriatric assessment by a local specialist.  These assessments are typically done when there is a patient, family, or physician concern around areas of competence.  Seeing this, I assumed there was an issue for this woman with one of the following: memory, dementia, compliance with medications, safety risks due to any number of conditions but often related to falls in the home, and/or psychiatric concern with anxiety or depression.  I didn’t know for sure what the concern was in this case as there was no specialist note available to ascertain what was discussed or what the findings were from her assessment.  This became a paramount part of the discussion that I had with this woman and her family.

The biggest part of my job on this day was to try to determine if it would be safe to give this woman chemotherapy if she wanted it.  She does not have much time left but there is data showing chemotherapy can prolong her time.  I always try to remember that just because we can do something, doesn’t mean we always should. Chemotherapy is not always the right answer for each person; sometimes chemotherapy can make a situation worse, speed functional decline, and/or cause side effects that may make any extra afforded time miserable time instead of well-lived time.  The bottom line is that every patient situation is unique and the decision to undertake chemotherapy must be weighed with care.

I asked this woman some get-to-know-you questions to start our conversation.  I could tell she was generally a well lady.  She looked her age.  She had few other problems with her health.  She answered my questions appropriately about how she found out about her cancer and what she understood of what she had been told to date.  She was able to describe her current cancer symptoms well – tiredness, pain in her abdomen, lack of appetite.  She also explained that she had recently been started on a water pill because her legs were swollen; she shared she was pleased with how thin her legs had become since starting these pills.  I explained why her legs were so puffy – that this was related to her cancer and malnutrition and the fact that her liver wasn’t working as well as it should be.  She nodded in understanding.

She faltered a little when I asked her some personal questions about where she lived and with whom.  She briefly thought her husband was with her instead of her son.  She corrected herself rather fast, however, when she looked over at her son and realized she was wrong.  When I asked about whether she could remember to take her prescribed medications, she stated she could.  Her son corrected her and reminded her that because she was in fact not taking these medications correctly, homecare was activated to come to her home and supervise her with her medications.  She was able to self-reflect on this and verbalize to me that she knew her memory wasn’t what it used to be.  Her son filled in the rest of the blanks about how and when these memory concerns started and that her slipping memory was the reason her family asked for a geriatric assessment.

This is what he told me: She and her husband of seventy years (yes, seventy – 7, 0 – 70!!!) had lived together in their house for fifty-four years. Just over a year prior, her husband had died of pancreas cancer.  In grieving that loss, it became clear this woman could not maintain her home and that her memory was failing at times.  Her family moved her to a condominium in a building for seniors.  She was still living independently but her memory worsened at that time. This can be common after the loss of a lifetime partner and a move out of familiar surroundings.  It was no one’s fault; it just was.

After I found out about all of this, the most remarkable part of our interaction occurred. I locked eyes with this woman and asked, “What do you do with yourself?  How do you spend your day?”

“I don’t know why everyone thinks I don’t have anything to do,” she replied.

“Oh, I didn’t mean I thought you didn’t have anything to do.  I am just curious about how you spend your time,” I qualified.

“Well, I have lots to do . . . and I think a lot,” she came back to me with.

I loved this answer immediately because I think a lot too.

“What do you think about?”, I asked.

Her answer was beautiful:

“I think about all of the wonderful things that this life has brought me.  I think about how blessed I have been to have the family I have.  I think about how lucky we are that we all love each other.  And I think about my dishes.  People don’t have good dishes anymore.  Why don’t people have good dishes anymore?  What am I supposed to do with all my dishes?”

I sat there in awe of this woman in that moment, thinking that this might be one of the most brilliant answers to any of the questions I have ever asked in a clinic room.  I could not have made up her answer if I tried a million times over with a million different patients. Her answer made me take a deeper breath, and then a very long and slow exhale.  Her answer touched my heart.

By the end of our visit, I had determined I did not think the risks of chemotherapy were worth the benefits in her case.  This lovely woman and I had a nice talk about the reasons why this was my recommendation.  Her family listened.  I told that in her condition, given how unwell her liver was and how frail the rest of her body was, I thought chemotherapy would make her sicker, quicker.  I told her dealing with her pain and symptoms as they arose would be safer for her than giving her chemotherapy, in my opinion.

She told me she understood and asked me what she should do with her dishes.  I suggested that this was entirely up to her but perhaps she wanted to spread them around to her family.  Her sons and daughters then asked me the questions they had about timelines, symptom management, being admitted to hospice as opposed to staying in her current living situation, and whether she should stay on the water pill that was started.  I talked through these things with them.  As for the water pill, I recommended it be stopped because of the risk it might cause in this woman’s particular case with electrolyte imbalances and dehydration.  I heard them tell me that since starting this pill, she was a little more unsteady on her feet and this made falls a greater risk for her.  This woman was disappointed with my “stop the water pill” recommendation because she knew this meant she would have to put up with puffy legs.

I left the room after telling her she would always have a beautiful soul, but she likely wouldn’t have beautiful legs again.  She seemed to think that was an acceptable way to end our visit – so did I.

When I closed that door, I was a little more grateful for all the people I love and I had a new found wonder for what I was going to do with my good dishes when my time was up.

Author notes:

I love this story as much as I loved the interaction I had with this woman and her adult children.  Hearing this woman reflect on her thinking and that her thoughts revolve around the loves of her life was impactful.

The picture I’ve posted with this story is a picture of a few of my good dishes. This woman is right in her observation that many don’t have “good” dishes anymore.  I am not sure that I would have these dishes if it weren’t for the death of my uncle.  It’s not lost on me that my uncle had rectal cancer too – his was adenocarcinoma.  His cancer ended his life in his early forties.  I choose to use these dishes randomly, often for no special occasion other than to dish out love by sharing time and food around the dining room table.

It is a great hope of mine that I live a long and well-loved life.  I hope I can make it to the young age of eighty-nine; if I’m lucky and look after myself, maybe I’ll even live a little longer.  After the interaction I had with this woman, I hope after a long and well-loved life, my greatest concern will be what I am to do with these dishes when I die.

I am curious to know what you think about when you think about the sum of your life to date.  What do you suppose you will think about when you know death is near?  What will weigh on your mind?  If it’s not a dish or two, what will it be? And if the thoughts which come are not those filled with gratitude and love, is there a desire to change your thinking, behaviour, and/or intentions before your time is up to get to a place within yourself where you might be able to say goodbye to this world with satisfaction and pride for a life well-loved?