Mr. JC died from metastatic colon cancer a few months ago. He was only forty-four years old. The day he died, his wife lost her husband, and his dog lost his best friend. We shared pictures of our dogs many times. The photo posted with JC’s obituary was a lovely one of JC with Sarg – JC with a big smile and Sarg with his tongue hanging out as far as can be. To honour JC, the picture I tagged to this story is of my puppy and me on an autumn day not dissimilar to what JC’s obituary picture looked like. JC’s story is one of the most solid surrenders I have ever had the privilege of learning from. I’d like to tell you about it . . . .
JC was diagnosed with stage four colon cancer in the spring of 2019 at the age of forty-one. He had a family history of colon cancer with a few other family members being afflicted, most notably his father who died from it at a relatively young age. JC was otherwise a well man with no other medical issues. He lived with his wife. He was a small construction business owner, having retired from his previous life in the Canadian military.
He presented to an emergency room after having excruciating lower abdominal pain in a Rona parking lot. Imaging showed a mass in his colon. He was sent for an emergent surgery to cut his colon tumour out as it was causing a bowel obstruction. During that surgery, surgeons documented cancer spread to his omentum, part of the connective tissue inside his abdomen. His CT unfortunately also showed liver and lung metastases, and retroperitoneal lymphadenopathy presumed to be related to his cancer. With all these areas involved, his cancer was not curable.
When I met him and his wife, he had healed well from his surgery. He was having back and testicular pain. Constipation burdened him. Understandably, he was experiencing existential distress. As it turned out, these issues would plague him for much of the remainder of his life.
At that first visit we discussed the natural history, staging, prognosis, and treatment of his disease. He was already aware that he had an incurable cancer. He wanted to know how long he might live and so we talked about average survival data with his type of cancer. I informed him he might have between two and three years, using our best treatments in sequence. I also told him that those were averages and that means fifty percent of people do better, while fifty percent do worse. He and his wife said they understood.
We talked about standard treatments and a clinical trial option we had available at the time, which included chemotherapy and an immune drug. I explained that no matter his choice, the goals of treatment would be to make him feel better and to try to help him live longer. He wanted to proceed with the clinical trial. He did this. Then, he did so much more. JC was a fighter.
For over a year after diagnosis, JC was at our cancer centre four weeks out of every six, or so, for his clinical trial treatment. It was a lot. When those drugs stopped working and his cancer started to grow, we switched to a different standard chemotherapy regimen which worked for about six months. When those drugs failed him, he went on to the next best thing, and then the next again after that. Each line of treatment worked for less and less time. Then, another clinical trial became available with a drug in early development. There was limited data on this drug. Even with no guarantee that it would work and a risk of unknown side effects, JC volunteered to participate in that trial too. This man would not give up.
Throughout all this treatment, JC showed up and gave it his all. Sometimes with his wife, sometimes alone, he would come to his appointments with all the grit he could muster. He would come and he would try. Some days weren’t pretty. In fact, many days were terrible struggles. He dealt with constipation and pain almost every day. We never really seemed to get a good handle on these for him, despite using all our tools. He struggled with his mental health, always trying to grasp at some semblance of happiness or joy but falling short with the heaviness of his diagnosis and the reality of his mortality. I think this, along with his pain and progressive physical weakness, hung heavily on him. I could see it in his eyes; on the really bad days, I could see it in the way he carried his anguish in his slumped shoulders and sad face.
JC was one of those patients I wish I could have just scooped up in a giant bear hug to make it all better like I used to do for my kids when they were little and fell, scraping up a knee that really only hurt a little and was fixed lickety-split when I pulled them in tight to make them feel secure. That kind of hug couldn’t fix JC. His was real pain: heart and soul pain etched into him so deeply because he would be leaving this world too soon. He had guilt layered on top of it all – a partner’s guilt, knowing he would be leaving his wife much too soon. He couldn’t fulfill the lifetime of promises he made to her because, try as he might, he would not be around. He told me once how crushed it made him feel knowing he couldn’t be there to comfort his wife when his cancer took him.
JC had so many complicated scrapes in his journey. These scrapes kept coming one after the other after the other. When he developed nerve damage from one of his chemotherapy drugs, we decreased the dose of that drug. When his neuropathy got worse, we took that drug away from his treatment regimen. When he was miserable from chemotherapy related fatigue, we stopped his chemotherapy altogether and kept going with just the clinical trial immune drug. When his pain flared, which it did frequently, we sought out help from our Pain and Symptom team who became instrumental in his care. When his mental health was failing, our psycho-social team was accessed; they counselled him to the best of their abilities for the duration of his time with us. The side effects of that last drug we tried, the new one, just about killed him. It landed him in hospital with intractable diarrhea. I thought he would die then and there but he still managed to rally enough to be discharged from hospital and show up in my clinic a few weeks later to consider yet another line of treatment.
Part of JC’s remarkable story is that despite his setback, he still did his best to truly live with his cancer. To the best of my knowledge, he and his wife bought their acreage right after his diagnosis. They fixed it up with many projects along the way. They landscaped and made a huge garden. They got a puppy named Sarg that I know JC loved very much. They camped with friends. Right before he died, he and his wife spent some time in Hawaii to just be present together without the burdens of clinic appointments. I know it was all of these things that kept him going.
With each failed treatment, JC’s cancer grew, and his body weakened. His liver eventually started to fail. At our last meeting, we still had one treatment option that his cancer had not been exposed to. I offered it to him. I told him we could try it if he wanted to keep trying. His simple yet profound reply:
“I’m done.”
Then, looking at his wife, JC said, “I am sorry.”
His wife, without delay, said, “No. Don’t be sorry. I am so proud of you. I got three extra years with you. I’ll take every moment I can get but I want you to be comfortable.”
There wasn’t much said after that in our clinic room. JC had decided it was time for his surrender. He knew.
Some people never get to this point. Surrendering is a hard thing. For those of us born with fight in us, me included, knowing when to wave our white flag, and being comfortable doing so, can be next to impossible. JC found a way to wave his flag at exactly the right time for him. I am so grateful for the privileged of being there to witness the strength of character it took to do this. I walked out of that room with tears in my eyes. Of course, I was sad about JC’s pending death, but my tears were there because I admired him so much for knowing he was done. Thank you for the stellar example JC. Much appreciated. I will remember you fondly.
Author Notes:
A few weeks ago, my best friend and I challenged ourselves on the Nepisiguit Mi’gmaq Trail in New Brunswick, Canada. This trail was touted as one of “twenty-five amazing journeys for 2022” by National Geographic. It was the only Canadian destination making the list.
We optimistically budgeted six days to travel the one hundred and forty-four kilometres of rugged backcountry terrain. This is a difficult trek. I know we both really wanted to see that end marker. Six days could have been enough in the best of conditions and with proper planning. But what we didn’t know ended up being part of the reason we didn’t complete the hike. We learned a tough lesson. We should have made a food and supply drop half-way through, so we didn’t have to carry as much weight in our packs. Even with the weight, we might have been able to complete the hike in its totality because we were pushing ourselves and each other. We came so close. But we didn’t make it. Just shy of one hundred and ten kilometers, on day five of our epic journey, we stopped hiking because of my feet. They were shredded.
My blisters started on day two and quickly worsened in the humid heat that had us literally dripping with sweat for most of each day. Our clothes, and socks, were continuously soaked through. Try as I might, with Band-Aids and tape and shotty wound care a la oncologist, not at all on par with my fancy plastic surgeon and wound care colleagues, I could not slow the skin breakdown or ease the agony I was in with each step.
It was such a hard decision to stop. I didn’t want to. I didn’t want to disappoint my friend. I didn’t want to disappoint myself. I didn’t want to fall short. But, with the help of some trail angels in the form of four other hikers that seemed to come out of nowhere and be at exactly the right place at the right time (which was particularly miraculous because in the previous one hundred plus kilometers we had only passed four other humans), and the love and understanding of my best friend, I was able to surrender.
I thought a lot about my patients on that hike. JC came to mind many times. I recalled how he fought for his time left here. I thought about how he got back up each time he was pushed to the ground. But mostly, I thought about that last day in clinic with him and his knowing declaration that he was done. He said it with such certainty. It was such a brave and beautiful moment.
I clearly have a lot of work to do to be better at surrendering when it is the only logical thing to do. It is amazing to me that some of my patients, especially JC, do it so well.
I am curious to know, reader, when was a time that you had to surrender? How did it feel? What did you learn?
