I’m At Peace

I met a new patient for a few brief moments last week. She had an impact on me that has and will extend far past the limits of our doctor-patient relationship. I will try to explain how and why.

Kelly’s (pseudonym) first appointment with medical oncology was in a resident’s longitudinal clinic. I supervise this longitudinal clinic. Residents are physicians who are completing their training in a particular area of medicine. My cancer centre is a teaching hospital affiliated with one of the Universities in our city. We provide clinical education for many specialties. This resident is a medical oncology trainee. He will complete his training and become a full-fledged medical oncologist in the summer of 2023. To help prepare him for independent practice, we provide our medical oncology residents the opportunity to follow their own patients. I am ultimately medico-legally responsible for the patients within his longitudinal clinic, but we try to ensure the resident works as independently as possible given each clinical scenario.

Kelly is forty-seven years old. She came to her first appointment at the cancer centre accompanied by her husband. Together, they have two teenaged children. She is an educator. She recently initiated her disability insurance because she could no longer function at work due to her cancer related symptoms. She has a devastating diagnosis: metastatic pancreatic cancer.

Kelly’s abdominal discomfort began in July 2022.  An ultrasound in October demonstrated liver metastases. A CT visualized a pancreatic body mass. One of her liver lesions was biopsied confirming cancer of the pancreas.

She has significant pain which is bad enough to keep her up during the night. She is on pain medication. When we saw her, she was not taking enough of these medications to take the edge off her pain.

She has lost a lot of weight over the last few months. This is no fault of her own. Her cancer does this. She is only able to eat less than half of what she could previously. She is plagued by nausea. She is taking regularly scheduled nausea medication to try to help ease this symptom.

Kelly is also increasingly tired. She notes an increase in drowsiness since initiating around-the-clock pain medication. She denies confusion. She is currently spending more than half of her day sleeping or sitting.

My resident colleague, Kelly, and her husband discussed symptom management and a possible treatment plan. Directions were given for how much pain medication to take, which medications to use, and when to use them. A recommendation from a pain and symptom team in the community was acted upon by requesting a consultation with one of our gastrointestinal interventionalists who might be able to achieve a celiac plexus block and biliary stent to, respectively, ameliorate pain and relieve probable progressive biliary obstruction.

The fact that Kelly’s cancer is incurable and life-limiting was detailed. Palliative systemic therapy to extend life and ameliorate her current symptoms was discussed. We generally have two different chemotherapy regimens to offer patients with stage four pancreas cancer. Kelly was too unwell for one of those options as it is harder to give and typically generates more side effects; we would likely make her symptoms worse if we tried these drugs in her case. Her liver is also functioning at a reduced capacity so even our less toxic chemotherapy might be challenging to administer easily. But we were willing to try if she was. If she accepts the risks of treatment, we could try to get a meaningful amount of treatment into her to see if we can stall her cancer enough that she might gain a little more time with her family. At our first meeting, it seemed she was leaning that way.

When patients are booked into the resident longitudinal clinic, I am the mop up crew. My resident colleague does all the upfront discovery and discussion. I go in to introduce myself afterward and ask if there are any further questions.

Kelly and her husband did not have any further questions for me. Instead, Kelly volunteered, “I’m at peace with my diagnosis”.

What a remarkable thing to say – “I’m at peace”. I am awe-struck in that moment. I didn’t know what to say. I embraced her comment like a gentle hug.

“I’m at peace” is not something an oncologist often hears at an initial consultation with a forty-seven year old woman, wife, and mother of teenagers, who is mid-career, and who should have a good thirty to forty more years of life ahead of her. This was one of those moments in clinic when the clock slows and the air gets thin. I didn’t want to breathe in or out. I just wanted to be in that cocoon of safety Kelly’s peace had just provided.

Kelly went on to say she has a lot of support from her family and friends, including her school and faith communities. I had no doubt that was true. She clearly understood her time before death was limited. She was also very certain about the peace she sat in. That room was so calm.

I would like to thank Kelly for those moments of awe in clinic. I hope she knows our team will do our best to hold her in her state of peace and walk along her chemotherapy path with her. I will trust that she knows if or when the burdens of treatment overwhelm her, her peace will surely carry her the rest of her way home.

Author Notes:

“I am at peace” has stayed with me since that visit. If I am being honest, it’s been bouncing around in my head uncomfortably poking my skull with each ricochet. My discomfort is born from honesty: I am not at peace. My wonderings of whether I will ever be fully at peace are the hamster in the wheel of my frontal cortex. Can I make the wheel stop?

I don’t think I would have the grace Kelly has if I was given her diagnosis. I have so much to do, so many places to go, so much more life and love and loss to experience. Kelly must have these feelings too. How is she at peace? Acceptance is probably the key. I applaud her. It is beautiful to see someone accept a diagnosis that is out of their control.

I was reminded this week of the importance of stillness. I wonder if I could bring more stillness into my life, would my peace amplify? Can I slow life, even just a little each day, to seek and find fulfilled in stillness? I think I want to try harder than I have been to do this. If only the day to day of life would stop getting in the way!

While I cannot say I am at peace, I can say I am much closer to peace than I ever have been. I have more peace of mind today than I did ten years ago. I have more peace in my heart than two years ago. I am mostly happy and being happy is a gift I am grateful for. I’d like to think experiencing the ups and downs of life has watered the soil which my growing peace has rooting itself in. Peace comes to me in pockets of time. When it appears, I know I get a little more still.

I am curious to know reader, are you at peace? If so, I encourage you to spend a few moments to be still and remember how you got there; if not, perhaps a little bit of stillness will inspire you to imagine what it might take for you to walk through the gates of peace before you die.

I wish you peace and joy during this holiday season. I hope you find a little time over the next few weeks to be still and assess where you’ve been, where you are, and where you might want to go with your heart and your soul in 2023.