If I were to say I had a stoic patient, what would come to mind? Would you think she/he/they were brave? Would you imagine someone who was calm under pressure? Would your brain make you think this person was a master at avoiding emotional extremes? If so inclined, come up with answers to these questions. Now, let’s see if you have the same conclusions after I tell you about Ms. L.
Ms. L was diagnosed with metastatic colorectal cancer in late 2019. Her cancer had spread to lymph nodes outside of the main area of her cancer making her disease incurable. Based on the location of her cancer, and the symptoms she was having, she received combined radiation and chemotherapy for six weeks. A surgery to remove her bowel tumour followed. She then saw me for consideration of chemotherapy. The goals of chemotherapy would be to extend her life, not cure her cancer.
I saw Ms. L for the first time in early 2020. She was seventy-seven at the time. She was an otherwise healthy woman who had required limited interaction with the healthcare system up until this point. She was not having much in the way of symptoms from her cancer. She understood her diagnosis. She knew she would die sooner than expected from her disease. She was interested in trying to control her cancer, to gain extra time, but only on her terms.
We talked about possible treatments at her first visit: combination chemotherapy regimens with optional add-on targeted drugs, singe-agent oral chemotherapy, clinical trials, and a watch-and-wait approach in which we would not embark on treatment yet, but instead defer chemotherapy initiation to a future date. We talked about potential side effect of chemotherapy. She was rightfully interested in how she would feel on any treatment and the longevity she might gain from treatment. My sense was that she would consider treatment if she was able to maintain an acceptable quality of life. She wanted to feel good. She wished to look good doing it.
I sensed Ms. L was a strong woman from the moment I set eyes on her. She appeared physically strong and fit for sure, especially for someone in her late seventies. However, it was more her strength of character that struck me. She looked me straight in the eye, always. She asked pointed questions with her pleasing-to-my-ear Irish accent. She considered my words before responding with her own. She chose her words carefully. She was certain with her answers. She was never afraid to break from, or delay, chemotherapy. She was loyal to commitments important to her, which kept her close to her wholehearted life more than chemo ever could. She also had admirable self-clarity.
Ms. L was not a touchy-feely person, at least not with me. Our relationship was more of a business type connection: necessary, respectful, to the point, transactional. It was exactly what she seemed to need. I was happy to oblige.
Notably, Ms. L had a flair for style. I admired this too, very much. Whenever my nurse and I saw her on our clinic slate for the day, we both got excited wondering what she would be wearing. I don’t think I recall an appointment with her when she wasn’t looking like she walked right off the page of a fashion magazine. She had matching pant and blazer outfits, long skirts and blouses with bows, vibrant patterns to make one’s eyes dance, all aligned with highlights of scarfs, necklaces, earrings, and bracelets. The colour mattered not – she could wear it all! From cotton candy pink to lipstick red, periwinkle to neon blue, canary yellow to sunset orange, this woman pulled it off . . . often in heels!!
Ms. L had the most fabulous shoes. Fluevog was one of her favourite brands. I’ve mentioned in a previous post that once upon a time, we both showed up to clinic wearing Fluevogs with ribbon laces. We had a grand laugh over the joy ribbons can bring to a person’s heart! I would hazard a guess she had an eclectic, and large, shoe closet.
I will never know for sure but perhaps her flair for style was part of her wish to not lose her hair with chemotherapy. Several effective chemotherapies for colorectal cancer do not cause hair loss. I modified my usual sequence of treatments in order to satisfy her wishes to avoid hair loss for as long as possible. We were mostly successful . . . until we could no longer be. However, man oh man, could Ms. L rock a beautiful head scarf!
In the beginning, Ms. L delayed the start of treatment for several months for family reasons. She had weddings to attend and a couple of great grandchildren on the way. Chemotherapy was not to interfere in those precious moments. She went on to received multiple lines of treatment over the course of two years, taking short breaks when needed for personal or medical reasons. We started with single agent oral chemotherapy. Her cancer behaved well on that for nine months. At progression we added an intravenous chemotherapy to her chemo tablets but quickly found out that was not working. We went on to try another option with a couple of targeted drugs. After three months, there was no improvement. We skipped back to the chemo pills with a different targeted drug. This ended up holding her cancer stable for eight months. When her cancer grew again, we switched to her last option – a different intravenous chemotherapy, the one we were trying to avoid because it causes hair loss. Her cancer progressed during this time, causing other medical emergencies which landed her in hospital. By the time we could try to squirt a bit more chemotherapy into her, her liver was failing. She was yellow. She was exhausted. She was dying.
When she came to clinic a few weeks ago, we knew it was her last visit. Ms. L was nearing the end of her life. I could see it. She could feel it. She didn’t have to come. I’m not sure she was completely up to it. But she came, nonetheless, I think to say goodbye. We dealt with the uncomfortable conversation around how much time she might have and what that time might look like. We talked about dying at home but that, if needed, a hospice bed was accessible. I knew she was going to leave this world the way she walked through her diagnosis and treatment – with stoicism and style. There was no doubt about it. She was going to leave this existence still looking like she was on the cover of Vogue.
Before I left the room that day, I shared the awe and respect I had for her and for the way she carried herself through her cancer journey. I told her it was beautiful to watch her come in each visit, knowing she was steering her own ship with whatever Super Powers she harnessed. I expressed my admiration for the confidence she had in her decisions and her resolve for living with her cancer instead of dying in her diagnosis. I also shared how fun it was to walk into her room each time to admire her stylish outfits and outrageously cool shoes. She was a cancer fashion mogul. I loved that about her. She taught me confident self-expression and colour boldness and a sureness for life that I hope I have when I am in my late seventies.
When I got up to leave that last day, I stretched out my hand to her. “Thank you, Dr. Spratlin,” she said properly and as firmly as she then shook my outstretched hand. I was teary when I left that room. Ms. L wasn’t. She still had the business of dying to take care of. Though cancer took her life, it didn’t take her spirit. She didn’t let it.
It was an honour and a pleasure to be a small part of your care team Ms. L. If your entire being didn’t scream dignity, I don’t know what might. I wonder where all your shoes are now. I hope your grandchildren and great grandchildren lovingly fight over them one day.
Author Notes:
The word stoic can be a noun or an adjective. Stoic is defined as by the Merriam-Webster dictionary as, “one apparently or professedly indifferent to pleasure or pain” and “firmly restraining response to pain or distress”.
Stoicism was also a school of philosophy for many centuries beginning around 300 BCE. Beliefs within this school included the notion that there is a rational structure to the ways of the universe with all occurrences due to cause and effect of other happenings. Stoics believed that while we might not be able to control events of the world, we could certainly control our approach to them. Stoics recommended self-improvement through four virtues: wisdom, temperance, justice and courage.*
When describing an individual, I might prefer the definition provided by essayist Nassim Taleb who wrote, “A Stoic is someone who transforms fear into prudence, pain into transformation, mistakes into initiation, and desire into undertaking.” This sentence wraps wisdom, temperance, justice, and courage into one giant perfect gift. In my opinion, this gift was Ms. L. She was a Stoic.
I wonder if this is her whole story though. I wonder this about many of my patients. Who are they really and how do they present themselves to the people they love and to the rest of the world?
I found Ms. L’s obituary online shortly after she died. There were some lovely pictures of Ms. L with friends and family included in her obituary. There was a video of Ms. L playing the game Pie Face®. Her smiles and the laughter that came after her face was hit by whip cream was priceless. That video was why I chose the photo that accompanies this blog post of me playing a game made by the same company. Yet another picture showed her playfully posing with a cutout of Pierce Brosnan. There was one of her on a motorcycle. And several of her with loved ones, all of them smiling away. One photo hit me hard – of Ms. L with her best friend from when they might have been in their twenties or thirties with words underneath the photo expressing peace to them was endless laughter. I can relate to this. Reading that caption made my heart ache for some time in the future when my best friend and I will have to part in death.
There are the sides of patients that doctors do not see. I think these sides, even if not known, are the ones we must always try to remember as physicians. Our patients are not just the people that present in our rooms. They have hopes and dreams and jobs and pets and hopefully people they love and that love them back. I sometimes go looking for a patients’ obituary as a way for me to pay my respects. Perhaps this helps with closure for me; I don’t know. But I do know obituaries can give me a special glimpse into a life. This is important for me. It’s a reminder that the next patient, and the one after that, has a life and loved ones – that they are people not diseases.
I am curious to know how you present to the world in times of stress, reader? Are you a Stoic or are you a little messy? Either way, are you comfortable with that or do you wish to change how you show up?
*A great summary of Stoicism can be found by googling the TED-Ed production “The philosophy of stoicism – Massimo Pigliucci”.
