Monday, August 29, 2005

The C-Word

Another week begins, yet I approach it with renewed energy and no post-vacation malaise. What a relief.

For those of you who were following the story of my patient with metastatic stomach cancer earlier this month (see The Language of Illness and Stories Unfolding), he's back home from the hospital and we are aggressively managing his nausea and other symptoms. Whether or not we move ahead with chemotherapy remains to be seen. He's not long for this earth and my goal is to keep him comfortable and free of unnecessary pain and suffering. Intractable vomiting and dehydration is no fun, and we've managed to put out that brush-fire for now. I stand ready for the next one.

Sadly, one of my favorite patients---a 69-year-old Puerto Rican woman (whom I see as a "free care" patient since she's too old for our program) with HIV, hypothyroidism, asthma, emphysema, diabetes, anxiety, and depression with psychotic features, is in the hospital with what appears to be metastatic cancer to her lungs from a mass connected with her thyroid gland. Previous biopsies of this mass in what is called her "mediastinum" (the upper chest area) have been benign, and I feel so badly that perhaps now the time has come where the mass has taken on more sinister and lethal qualities. An avid smoker, she goes through one or two packs a day, and a great deal of my time has been spent trying to convince her to quit smoking over the last four years, all to no avail. With her HIV and diabetes under perfect control, I have focused on her respiratory health. It is a widely held opinion that one cigarette can be the one that activates cancer cells to begin their uncontrolled growth, and this is the turn of events which I have most feared.

My connection with this sweet woman is precious. Since she speaks no English other than being able to say "good weekend" or "I love you", our relationship is conducted entirely in Spanish. Every time we converse---whether it's on the phone or in person---she insists on asking me how my wife, son and dogs are doing, and smiles so beatifically as I recount for her my son's latest accomplishments, my wife's career changes, or the dogs' latest trip to the vet. I also ask about her family, and we always close our conversations with "Dios te bendiga" ("God bless you"), a salutation which I freely share with many of my Latino patients as a way to respect their cultural practices. She carries a bright light within her, even in moments of paranoia and fear when her face is mask-like and stiff. Over the years, she has fed me Puerto Rican food, brought me countless bags of plantains to bring home to my family, and will settle for nothing less than a kiss on the lips when saying goodbye. I always comply.

Today, sitting on her hospital bed and chatting, she seemed to have no idea that we are suspecting that cancer is growing within her. I hinted that we were going to run some tests and do a biopsy, but I hesitated to use the "C-word" just yet. Her mental health is tentative, and I didn't want her to lose sleep tonight unnecessarily. When the results are in, I'll make sure that I'm present for the conversation in which we inform her of the cancer and how it has spread. For now, I cling to the very dim hope that the shadows on the CT-scan were not metastasis, and that the mass is localized and operable.

She would be the third patient on my caseload with active cancer, and the burden which these individuals carry along with their families and loved ones is great. I do my best to walk alongside them on this difficult path, but it cannot be more true that one must always walk alone when faced with mortality and death. Courage and optimism go a long way, but misery and depression certainly play their hands as well.

It is these moments of profound humanity which most engender one's humility.

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