In early 2014 I met an unassuming man of small stature who had just had a rather large surgery to remove his cancer – an ampulla of Vater tumour. These are uncommon cancers and though there are many nuances, they are commonly treated like pancreas cancers. He was one of the “lucky ones” who could have his cancer cut out for possible cure. This is more rare than the alternative.
I remember my first impressions of this man: he seemed gentle and fit. The gentleness shone in his sparking eyes and shy smile, which I came to enjoy trying to bring out during our subsequent visits. I could tell this man had tried to take care of himself physically during his seventy-odd years. Despite just having had a complicated surgery, he had a good amount of muscle definition in his arms and legs.
We talked about his cancer at our first meeting in detail – the location, the chance of cure with and without chemotherapy, the chance of recurrence, the fact that if he did have a recurrence his cancer would then be incurable, the recommended chemotherapy, the side effects of chemotherapy. His wife, who accompanied him to our first meeting, did not say much during our discussion. She was his stoic support.
The data would suggest there was only a small chance of improved cure with six months of an almost weekly intravenous chemo treatment; it was actually much more likely that chemo would only delay his cancer recurrence. This chemo was, however, his only chance to eradicate any left over cancer cells that still existed in his body before these cells had a chance to grow and spread to eventually cause his death. He decided to pursue the chemo with hopes he again would be one of the “lucky ones”.
For six months he made trips to our cancer centre twice a week for three straight weeks. The first of these visits each week was for a bloodwork and a side-effect check, sometimes with me, sometimes with our nurses; the second was to get his intravenous chemotherapy drug. The drug took about 30 minutes to infuse through one of his arm veins. Every fourth week was a week off.
He did splendidly by all accounts. He had limited side effects and his spirits remains steady. He did fatigue a little more with each dose toward the end. Then finally, his treatment was complete. He made it through the six months better than most people half his age.
Instead of giving him a clean bill of health at that time, I told him we had to repeat a CT to ensure we couldn’t see any cancer. You see, this cancer tends to grow back rather fast, I explained. Before he graduated from the cancer centre, we needed to be sure his scan was clear.
His scan was not clear. It was, instead, very full of cancer spots. The surgery and chemotherapy had not cured this man’s cancer. His cancer had other plans.
I gave him a revised prognosis with his wife by his side. His cancer was now considered terminal. He would die from his cancer, probably within a year. “We can never predict these things,” I told him. All we have are average lengths of life taken from clinical trial data. “The person in front of me is never an average; you are an individual who makes up that average,” I said to him.
I went on to tell him further chemotherapy could prolong his life. We had two different groupings of chemotherapies that we could try, using one grouping first, until it stopped working, then changing to the next grouping. After that, there would be no standard treatments possible and care would be focussed on pain and symptom management until his death. I explained taking chemotherapy breaks would be possible. The balance between quality and quantity of life was discussed. He impressed upon me in a soft way that being able to live – really live – while he was still in the land of the living was important to him. He had things to do and places to go and people to see. He knew chemotherapy might help him get to these things and places and people but he wanted to feel like he could enjoy these experiences and not be suffering through them.
We shared a quiet understanding that he would take chemotherapy and find a balance that felt right for him between his treatment and his living of life. I’m not sure if we actually ever set that as an outward intention. We both just had a healthy respect for his wishes and an open line of communication when treatment decisions had to be made.
And so on he went, taking chemotherapy for a few months at a time and then taking breaks without chemo for a few months at a time. He had side effects, of course, mostly increased tiredness and lack of ability to do much of what he wanted during the worst of his fatigue. We would take breaks when that happened for him to recover and go about his living. A few weeks to months later he would return for more treatment. This pattern continued for over two years through both groupings of chemotherapy drugs I could offer him. All the while, he did his job of living and I did mine of giving him his treatments, when he was able and willing. He was remarkable.
I was informed of his death in June of 2017. He was on one of his treatment breaks when he died. We did not have a chance to say a proper goodbye. At that time, I believed that to be the end of our journey together. I was wrong.
In the spring of 2020, almost three years after his death, I received a one page, hand-written note from his wife with a very special gift. The single piece of paper came from one of those small coiled scribbles, the edge of the note still spattered with loose paper pieces from where the coils ripped the sheet. She wrote:
“Dear Dr. Spratlin,
Perhaps you don’t remember the pleasant man in his seventies who came to you for his chemo treatment, but I want to thank you, belatedly, for all your help and encouragement. [My husband] died, went to be with his Lord, 3 years ago, and I am just now writing. I’m so thankful that you were able to prolong his life, but even more that you gave him the gift of allowing him to be in charge of his treatment – how often and how long. You helped him to keep his dignity and to have the chance to take his family to Mexico one last time. Many doctors would have pushed for more treatment, but you let him choose, and didn’t make any dire predictions.
[My husband] was only in hospital for a week before his death. He had been to the mountains, taken a short hike and visited his brother and sisters the week before. He passed on with a smile. We thank God for your kindness and care for him. It has meant a lot to me to know that he was at peace and had felt that he had a say in his treatment decisions.
Many blessings on you and yours.”
With this lovely note, she included a priceless gift: a bookmark that this man had kept in his bible.
It is a simple bookmark, made of thin cardboard. It is laminated. There is a mauve ribbon at the top, frayed at one end more than the other, and tied with a simple knot. This bookmark has one word on it which is coloured in with various shades of pencil crayon. The word on this bookmark is “HOPE”.
I remember you, pleasant man in your seventies. I always have. I remember your quiet demeanour. I remember your kind eyes when they met mine whether we were sharing good or bad news at our visits. I remember how impressed I always was when you came to your appointments looking so fit and telling me about your hikes and your bees with their nectar, from which you handcrafted delicious honey. I remember you knew when you wanted treatment and when you knew you had better things to do with your time left on this earth. I remember I knew these were your choices to make. And, I remember that I loved this about you.
This man lived while he was dying. He did the best he could with trying to extend his time doing the things he loved, with those he loved. He somehow, very quietly, mastered the great balancing act of obtaining quality and quantity of life, in a physical space where he knew the quantity was much shorter than he hoped and anticipated, and in his heart where he knew his version of quality of life transcended the time he was offered.
Please know I remember you, pleasant man in your seventies. Bravo to a dignified journey – a journey that I hope you felt was a journey well-lived. From my point of view, it appeared that way. Bravo!
Special author notes:
I remember the day I received this heartfelt note and gift. I was sitting in my office when I pulled out the little piece of paper and bookmark from an envelope. Tears came to my eyes as I read what this man’s wife wrote to me. I was at a rather low point emotionally and spiritually, and had been for many months prior to receiving this – not because of work, but because of personal and family stressors that seemed to have no solutions. In what I now believe to be strange twists of fate and/or unexplained universal powers, the signs that prompted me to move forward with some necessary changes were hitting me so hard they could not be taken for happenstance. This note and bookmark were a part of that magic for me.
Perhaps this man and I didn’t say goodbye all those years ago beause our paths were meant to cross again in a fantastical way through his wife and his bookmark; or, perhaps not. Was the timing of my receipt of this note and bookmark coincidence or was this a time-stamped message delivered at exactly the right moment in my life? Did I only catch this message because I was paying attention? If this message was sent and received at a different time, would there have been as much of an impact on me? Who’s to say?! The answers to these questions will remain mystical unknowns. It is my belief that life is amazing in so many ways. I am still learning I have to be alert and bold enough to pay attention to the signs presented to me to see all of the amazing. This man saw his amazing. He is inspirational to me.
This man and his wife showed me hope breeds more hope. Hope can be modelled. Hope can be shared. It can be kindling for a little flame that some think is missing but that still exists somewhere deep inside of us. I’d like to think most of us have that little spark of hope in us always. It can be lost for sure, but lost can be found with the right amount, and type, of fanning.
This man’s bookmark now marks the page of a special book of mine. Each time I changed the page, this man, his wife, and his family come to mind. A message of HOPE also comes to mind, as does the fact that my hope spark was fanned by this man, his wife, a short note, and a simple homemade bookmark.
I promise to pass this man’s bookmark on when my time is up. I hope it ends up in the hands of someone who knowingly, or unknowingly, needs a little fanning in the direction of HOPE.
