The first meeting I had with Mrs. M is burned into a part of my brain. It will stay there as if I’ve been branded, a forever memory.
Mrs. M presented to my new patient clinic one year ago. She came with her husband. They were equally lovely, quiet-spoken with delightful Irish accents, highly anxious, and very scared. Mrs. M was seventy-two.
About six months prior to our initial visit Mrs. M started having back pain. This back pain was not static. She described that her pain seemed to move around both of her sides and sometimes all the way into her right lower abdomen. Her pain was severe enough that regular over the counter pain medications did not allow for much relief. Considering this and that her pain was starting to limit her ability to function normally, her family physician prescribed an opioid. Mrs. M was using her pain medication rather religiously. Other than this pain and a little more tiredness, she told me she seemed to think she was going about her life as per usual.
Mrs. M denied any other history of medical issues except for a long-standing affinity to lung infections which cleared easily with antibiotics. She had no family history of cancer. She lived with her husband and had two adult children. She was a never-smoker. Her alcohol use was minimal and she did not dabble in any other drugs. She was a retired languages arts teacher and had spent many years devoted to her local school board. By her account, she had lived a very well life – physically, mentally, and emotionally.
Her pain prompted investigations including X-rays of her back and an ultrasound of her abdomen. These tests did not reveal a cause for her pain. Yet, her pain persisted. A CT of the chest, abdomen, and pelvis was then completed. The CT confirmed a mass in her pancreas and innumerable liver lesions. A biopsy of her pancreas followed. The biopsy was positive for the commonest type of pancreas cancer that is diagnosed worldwide – adenocarcinoma.
I learned all these things about Mrs. M first from her electronic health record and then from interacting with her in a clinic room. She spoke slowly and softly while she answered my questions. She was purposeful with her responses to me. Her explanations of what she understood about what was happening in her body were thoughtfully clear. I could tell she was an expert in explaining things to people who were not in the know, so to speak. Certainly, the teacher in her, the educator, was still hard at work.
Mrs. M, her husband, and I had the same extraordinarily hard discussion I have with most of my pancreas cancer patients. I had to share the news that her cancer was not curable. She already knew this but the confirmation of this fact by me, the cancer specialist, brought tears to the eyes looking back at me. I discussed the possibility of palliative chemotherapy which might allow more time for her and might also cause side effects, the severity of which were generally tolerable but of course we wouldn’t know unless it was tried. Most difficult of all was telling her that on average, without treatment, she would have six months or less of life, and with treatment, should she be able to tolerate it and if it worked, we might be able to extend that length to an average of one year. We also discussed at length the very real choice of not using chemotherapy. We could instead manage her pain and other symptoms as they arose, to give her the best quality of life during the time she had left.
Mrs. M did not know which decision to make. She left that first appointment with her husband to go home and think about her options.
There was a lot of meat to the first visit I had with Mrs. M and her husband. Much information was exchanged. A multitude of emotions were expressed and, no doubt, an equal number of feelings were held inside of her – to digest, to get acquainted with, to suppress, or to explore. That was up to her. I believe she evaluated her emotions and feelings in great depth in the days that followed our appointment as she struggled to make her treatment decision.
From my perspective, the highlight of my relationship with this woman occurred halfway through our first visit. It was not the history I took from her that was impressive; her cancer history could have been that of any hundreds of pancreas cancer patients I have had the privilege of serving over the years. It was not the ensuing discussion she and I had about treatment options or average expected survival; this part of our interaction went as I would have expected with a few tears, a little disbelief, and visible sadness. No, it wasn’t any of the normal things that occur during a first visit that has stuck with me from Mrs. M.
What struck me most from our meeting was a fleeting, near ungraspable, moment during the physical exam I performed on her. This exam was not notable because of any significant physical finding. In fact, her physical exam was mostly normal. But what happened that was so remarkable was an intimate exchange of words from her mouth to my ears that sent a shot of electricity right into my heart from hers.
I had run through the usual start of my physical examination. I felt her neck for lymph node spread – none was found. I placed my stethoscope on her back to listen to the steady rhythm of her breathing in and out. There were no crackles or wheezes to indicate a lung infection at that time. It was when I moved to put my stethoscope over her left anterior chest wall to hear the lub-dub, lub-dub, lub-dub of her heart that magic occurred.
She was sitting up on the examination table facing forward toward a drab wall. I was standing to her right. I had my left hand on her right shoulder. My right hand held my stethoscope which was pressed gently against the skin of her left chest just above her breast and to the left of her sternum. Lub-dub, lub-dub, lub-dub, lub-dub . . ..
Almost in between heart beats, as surely all else had gone silent, she turned her head ever so slightly to the right to meet my gaze. Her baby blue eyes met my green ones. The lub-dubs stopped lub-dubbing and she said as softly as she audibly could while blinking back tears, “I didn’t think the time would pass so quickly.”
BAM! Lightning-like electricity connected my heart to hers.
What a beautiful sentence: “I didn’t think the time would pass so quickly.”
There was nothing I could say in that moment to take her sadness away. I looked her in the eyes. I acknowledged her with a smile that she could not see under my mask, but I knew she saw in the crinkles of the corners of my eyes. Her lub-dubs continued. Lub-dub, lub-dub, lub-dub . . ..
Mrs. M did, in fact, decide to pursue chemotherapy. She had four doses of two chemotherapy drugs called gemcitabine and nab-paclitaxel. This two-drug combination is a standard first-line treatment across the world in the setting of stage four pancreas cancer. Gemcitabine and nab-palcitaxel is generally well tolerated and most side effects are manageable. However, Mrs. M did not like the way the drugs made her feel. She quickly realized what was best for her was living out the rest of her life with her family and friends close, being satisfied that she gave treatment an honest try. She gracefully discontinued chemotherapy.
Mrs. M died a few short months later. I like to believe “I didn’t think the time would pass so quickly,” was one of her final thoughts. I am honoured Mrs. M felt safe enough to share her thoughts on time with me. I hope this story similarly honours her memory.
Author notes:
I was recently in Toronto for a hockey tournament with my son’s team. My son and daughter and I brought my parents along. You see, my mom has family in the area – an aunt who is ninety-two, and her little brother and sister-in-law. My kids and I thought it would be nice for my mom to see her family; it had been a long time since that had been possible.
As one would expect, there was a lot of reminiscing when my family got together. My mother and great aunt spoke of the “good old days”, remembering my mom’s parents – my Babcia and Dziadzia – and some of the shenanigans that went on when they are all growing up in Montreal many moons ago. They remembered fond times they spent together and a moment when I might have been six and my great aunt asked me what I wanted to be when I grew up. I apparently stated I wanted to be a doctor. My great aunt thought it was the most remarkable thing I made that happen. I do not recall her question or my answer, but I guess even at such a young age, I had an inextricable calling to my profession.
My mother and her brother talked about their parents, about growing up, and about their kids having kids (me 😊) and, of course they talked about their grandkids. How did they get old enough to have grandkids?! They talked about their heart problems and their arthritis and the need for hearing aids. Indeed, where did the time go?!
Sitting there with my mom and our relatives last week made me think about Mrs. M and her gentle haunting words. It made me think about the fact that fifteen years ago, my son stretched out head to toe, fit between my wrist and elbow and now, instead of me giving him piggybacks, he gives them to me. It made me think about how from the time my daughter could walk and talk she would randomly just stop me five or six steps from her saying “Mama, stop! Ready?”, and then comes running at me full tilt to jump into my arms landing in a full-on koala bear hug, trusting I would catch the full force of her; this continues, and though catching her gets more difficult as the months and years pass, I still manage to do it because I never want the “Mama, stop! Ready?” and her trust of me to end.
Why is time so flippant? We often want time to fly by – to get through a long workday or to pass quickly so that we can get to the weekend or to that event that we have been on the edge of our seats waiting for. But we equally often wish for time to slow – to enjoy every second of our vacations or the fleeting moments of the coffee or tea we are having with a friend we haven’t seen in many months. Time is such a smorgasbord of wants and wishes, of riches and rags, of hopes and disappointments, and of miracles.
“I didn’t think the time would pass so quickly” will always be a reminder for me of how quickly life can speed by. It is a dramatic reminder that the end comes faster than we think it will.
What do you think things will look like for you, reader, in retrospect, when your time nears its end? Will your timeline be a giant fast-forwarded blur? Will there be moments where the reel is slowed into moments of motions you wish to recapture? I am curious to know . . ..
