EP has been my patient for almost a year. He has a diagnosis of metastatic colorectal cancer. Some people would have written him off as a lost cause and given up on him, but I have a soft spot for him. I haven’t given up on him. More importantly, he hasn’t given up on himself either.
When EP was diagnosed with his stage four cancer, he was homeless, and had been for a while. He has polysubstance use disorder; in other words, he is an addict. He was actively using multiple illicit drugs, most commonly fentanyl, when he presented to a local emergency with significant pain in his lower pelvis. He also had rectal bleeding.
He was admitted to hospital to investigate his symptoms. It wasn’t long before he was told he has incurable bowel cancer with spread to his liver and lungs. For almost three months he stayed in hospital, in part to receive palliative radiation to help stop his bleeding, and in part to figure out where he might be able to live post-discharge. There was a lot of reluctance to discharge him back to the streets.
While in hospital, efforts were made to get him off fentanyl and into a drug rehabilitation program. He refused participation in twelve step programs, but he did consent to the use of Suboxone, a drug known to reduce mortality, cravings, and withdrawal symptoms in opioid addicts. When we met, EP had been clean and sober for over three months.
During our first meeting, I confirmed EP knew his cancer was terminal. He did. We discussed prognosis to ensure he was aware of an approximate timeline for expected survival. He appreciated that. EP and I then had a very good discussion about quantity versus quality of life.
His initial terrified response to my inquiry about whether he wanted to pursue palliative chemotherapy was that he’d be better off going out and overdosing on fentanyl in one last large hurrah. I told him that would certainly be one of his options. I said it just like that too, “That would certainly be one of your options.” He looked at me funny then.
I continued to explain that no one could make him do, or not do, anything. Chemotherapy might control his cancer and help him to live longer but we were not going to be curing him. It was his choice to try chemo, just as it was his choice to leave the cancer centre and find some drugs or leave the cancer centre and remain clean for that day.
I envisioned EP in the shallow waters of an ocean beach like my daughter and I years ago. Waves of various sizes representing his addictions and his cancer rolling toward him as he stands in the water twenty feet from shore while the tide comes in. He is knee deep in water. The waves are building. He must decide how he might try to stay standing or if he will let the water take him. Does he brace himself with two feet on the ground, sand beneath his feet? Does he jump over the wave, one or two feet at a time, hoping he will land upright? Does he grab on to someone else’s hand for a little extra support and encouragement? Or, does he let his legs buckle and allow the waves to take him, first pushing him over, toppling him under water. The initial impact a bit of a shock pushing him against the ocean floor, back toward shore. But soon, the undertow takes him and swiftly sweeps him out to sea while he flails and gasps for air until fatigue sets in and his body surrenders. He doesn’t have much time to think about the choice or the impact it will have. He must decide. The waves are coming . . . .
We talked a little more about his mental health and whether he was suicidal. He promised he had no intentions of self-harm. He asked a few good questions about chemotherapy and side-effects. Then, he said he’d like to try the chemo. And so, we did.
It was not lost on me that EP had essentially been trying to kill himself, sometimes slowly, sometimes quickly, with his addictions since he was a teenager, that he had multiple near-misses of death by overdose, and yet here he was, consenting to life-prolonging chemotherapy treatment. Addiction, cancer, and the way the human brain reacts and reasons with itself is such a remarkable thing. The hope a human spirit has for betterment is astonishing.
EP remains on chemotherapy. His cancer is responding. He comes to his appointments . . . mostly. He is angry a lot of the time. He is depressed. He tells us these things but also tells us he has no plans to physically harm himself. I don’t actually know if he has remained clean throughout his treatment to date. He denies using when I ask him point blank. That is as much as I know. We have an understanding that I expect him to treat our staff with the same respect that we are treating him with. This seems to mean something to him on most days we see him.
EP is wrestling his cancer while fighting his addictions. These acts are miracles of hope. I’ll continue having a soft spot for him as long as he does the same for himself. Thank you, EP, for not giving up on yourself. There is hope, in the darkest of places, if we look for it. You are a perfectly imperfect example of this.
Author Notes:
The most difficult thing I had to deal with this week was trying to decide if it was safe to travel to the country my family is planning to visit on a summer holiday. This trip of a lifetime is an experience I so badly want to share with my most special people. At the time of booking, we thought the greatest challenge in making this trip happen was another possible Covid wave that could restrict air travel again. We had no clue political unrest would be the reason we might have to utilize the trip cancellation insurance we purchased.
For almost a week, we went back and forth with each other, with our travel agent, and with the tour company we are using, trying to get the most up-to-date information possible to make the safest decision for our family. Each day was fraught with indecision and uncertainty. Do we cancel? Do we hang tight to see what tomorrow brings? How long can we wait to decide? What’s our plan B trip going to be? How will we know for sure? Will we get all of our money back? There were so many unanswered questions. But that is it! That is all I had to deal with: my first world problems of privilege while I live with emotional, social, financial, and spiritual security. Was it stressful? Of course. But the decisions that had to be made were miniscule compared to the ones faced by EP every day.
EP reminds me how different life might be for any one of us if active addiction swallowed us. The choice of the day would be between spending money on drugs over food, not where to vacation. Each day would bring the decision to stay clean or give in and use, which would also be a decision to roll the dice on death, the risk of overdose looming ever large. Exhaustion would come from mustering the mental fortitude to hang on, one minute at a time, not wanting to use but also wanting so badly to use because it is the only solution that has ever brought comfort in an uncomfortable world. There would be unmanageability from a hazy recognition that life screams a louder death call each day. And then, for EP, the unfortunate secondary diagnosis of another incurable disease – a double whammy of addiction and cancer. How much can one person take?
Substance use disorders/addictions are mental health illnesses. They are diseases, just like cancer. They have proven over time to be just as, if not more, challenging to treat and there is no known cure. Those afflicted are in a fight for their life each day, and when the drugs or booze win, there is no place to go but down a dark, deep tunnel, that leads to either death, or an eventual rock bottom that might just be bad enough to force a drastic change in beliefs and behaviours.
I wonder what impact EP’s cancer wave and the courage it takes to face such a diagnosis will have on his addictions. The evidence so far is that he is choosing bravely to fight for life. I applaud him.
I am curious to know, reader, if there has been a pivotal moment in your life where you decided to fight for yourself in the face of despair? What did you learn? How did you grow?
