I will always remember the initial consultation I had with RF. I met him a few weeks ago when he came to see me for his newly diagnosed stage four colon cancer. He was accompanied by the daughter he lives with. A biopsy of his sigmoid colon mass showed areas suspicious for invasive carcinoma. His CT revealed multiple liver and lung nodules. His diagnosis was confirmed with a liver core biopsy which was consistent with cancer spread from his colon. His cancer was labelled stage four because of his unresectable liver and lung metastases. He had almost certainly been told somewhere along the way he had a terminal diagnosis. However, if he had been told, he did not hear, register, or comprehend the meaning of the prognosis his other doctors told him. He did not understand his cancer was incurable and that his allotted timeline might be as little as a few months without intervention or, at most, a few years if we could use our best treatments in sequence.
RF’s primary tumour in his colon was bleeding. In attempts to halt the bleeding, radiation was administered a few weeks prior to our meeting. He was seeing me to determine if he might be a candidate for palliative chemotherapy.
RF told me he did not have any cancer-related symptoms other than rectal bleeding which had significantly decreased since completing radiation. He said he would not even know he had cancer if it weren’t for that.
RF has important medical history to consider. He is a large man with congestive heart failure, hypertension, type 2 diabetes, chronic renal insufficiency, hypothyroidism, sleep apnea, and terrible osteoarthritis. His arthritis limits his daily activities. He is in so much pain when trying to mobilize that he does not really move much at all. He was waiting for bilateral hip replacements when his cancer was diagnosed. There is no way he will get hip surgery now; stage four cancer patients are always pushed to the back of the line, all but erased from the slate, for these types of elective surgeries.
Each of these items on RF’s list of ailments alone could be problematic for me as a chemotherapy doctor to concoct a decent treatment plan for him; put them all together though and RF’s cancer becomes very difficult to treat safely. As I explained this to him, I could see understanding sinking in. His eyes got a little darker. His shoulders slumped a little deeper. His inhales and exhales got a little shorter.
He asked me if he was going to die. I said we are all going to die but with his stage of cancer, he will die a little sooner than he otherwise should. I told him his cancer death call had competition from his heart disease, but that it is likely his cancer would kill him first. He nodded.
We talked about treatment options. I shared with him how the risks of treatment might outweigh the benefits in his case because of his multiple co-morbidities. We discussed probable and improbable side effect of chemotherapy and how those toxicities might be worse in him compared to other patients who do not have the same degree of heart and kidney dysfunction. I explained if he were willing to accept the risks, I would work with him to find a safe option to treat his cancer.
He took it all in. There was silence for a few long seconds.
“I’d like to try,” he said.
And then he shared some magical words with tears in his eyes:
“I know I’ve done right by my kids. I did a good job. I’ve had a good life. I’ve been happy. I know this. I know I did good.”
He kept talking after that, switching topics. I did not register what words were now coming out of his mouth. I was stuck on what he had just finished saying.
He did right by his kids. He did a good job. He has had a good life. He’s been happy. HE KNOWS THIS!!!
I interrupted his talking to acknowledge the profound (to me) declarations he had just made. I expressed my appreciation for what he verbalized. I pointed out how amazing it was that he knows this about himself and his life. I told him it’s even more amazing that he can say these things out loud. I told him how beautiful it was to hear this coming from a man, a father, a grandfather. I explained I often sit across from patients after I have given them a terminal diagnosis and hear them express regret for time wasted or lost or underappreciated. Yet here he was, recognizing his successes and happiness in the face of his mortality. This was a moment I do not often witness in my clinic. This was a precious moment that needed space.
I left this consultation in awe of RF’s life well lived. RF’s positive self-assessment gave me hope that when the end comes near, it is possible to look back at our life journey with a tear in our eye, a smile on our face, and a heart open wide enough to acknowledge all the good things found along the way.
RF sat with dignity in our new patient clinic room. His dignity made tears – a salty mixture of sadness and gratitude. This moment hit me hard in the heart. Thank you, RF, for allowing me to be part of those minutes with you and your daughter. It was beautiful to witness.
Author Notes:
The day I met RF I left the city to spend a long weekend in the mountains. It was a glorious three days with my Partner in Crime, hiking up and down mountains with our packs on our backs, crossing fast moving streams while balancing with our poles, and getting sore in all the right places that need to be conditioned for our upcoming longer trek.
Our hikes were metaphors for life on that trip. Some went as planned with expected ups and downs and a thrilling view of a mountain lake or breathtaking waterfall at the end of the trail. Some were nothing like we thought they would be with flooded out trails from much too much rain, blockages from avalanche paths requiring traversing downed trees and bushwhacking branches, and haphazard map navigation when our trail disappeared as we ascended past the snow line. The elements turned us back at points where we had hoped to continue trudging. We had to accept the conditions and pivot as required. Through it all we endured and even thrived. It was hard and rewarding. Each time we tie up our hiking boots, I get the same feelings: I am proud of us and I am grateful for the nourishment a magical person, place, and time can provide.
At many moments during the weekend, I thought of RF and how his “I did good” wisdom intersected with our hikes. Unlike RF, we were never in a life-or-death situation. But I know my attitude was just the same as his after our twenty-five-ish kilometer days. I have a good life. I am happy.
RF reminded me I want my life to be something I am proud of. Having a positive outlook isn’t always easy for me. The choices I can make around work-life balance, partnerships, and coping mechanisms can keep me from seeing sunlight at times. I recognize now this is all part of growing up and growing into, and then out of, my ever-shedding skin. I can look back and see my avalanches, floods, and indiscernible (at the time) paths have had purpose. Perhaps this is part of the reason I recognize a lightness in myself now – because I know there have been long stretches in my life where this wasn’t so.
I know my turn will comes when my time left is short. Between now and then, for each today, I hope I heed RF’s wisdom of “doing good” and knowing it. I don’t want to leave anything on the table. I want to slide into death, out of breath, with wild eyes, appreciating the crazy ride of life I just had. I want to recognize my valleys have merit in that they allow my mountains to be a little bit higher – a longer climb up, perhaps, but worth every step. I want to trust I can say, as RF did, “I did right by my kids. I did a good job. I had a good life. I’ve been happy. I know this.”
I am curious to know, reader, would you say you have had a good life? If you got told tomorrow cancer would cut your life short, could you look back and say you know you did good? If so, why? If not, what would you have changed?
