As my patient looked on, his wife took the framed photograph out of a nondescript manila mailer, the type with bubble wrap on the inside, and handed it to me gingerly. It was clear they both considered it to be precious cargo.
“You can see I made it to the wedding,” he said, smiling broadly, as I studied the image of him in a suit, locking arms with his granddaughter, the bride. The two of them were bordered by the opened doors of the church, stained glass windows on either side, his face bearing that familiar look of consuming love, joy and pride — along with a little fear, that at any moment he might start sobbing in front of all of his buddies and co-workers attending the ceremony. I have the same photograph in my own wedding album, of my father-in-law with my wife-to-be.
“You should have heard the gasp from everyone in the church when he came through those doors with our granddaughter,” his wife exclaimed. “I mean, no one thought he would even be there!”
“My granddaughter and I had been planning it for months, but we didn’t tell anyone,” my patient went on, explaining that he and his wife had raised the girl for several years while their daughter, who had gotten pregnant in her teens, could get back on her feet.
When it came to his health, my patient is the type of guy about whom you might say if he didn’t have bad luck, he wouldn’t have any luck at all. Years earlier, he was treated for colon cancer. Now, possibly as a result of that treatment, he had leukemia. But he also had a completely different type of bone cancer, and the kicker — advanced lung cancer.
He wasn’t the first patient I had ever treated with multiple cancers, and in general we approach people like him by going in order of treating the most serious cancers first, and working our way down to the less serious ones. In one respect, he was lucky: he looked a heck of a lot better than his medical chart. As leukemia and lung cancer often represent the worst of the worst, we tried treating both at the same time. The leukemia went into remission. The lung cancer didn’t.
Within oncology, it is taken as almost a truism that people die only after they have said their goodbyes to their immediate family, or achieved some life milestone. Countless times I have seen comatose patients linger until a child flies in from California, only to pass hours after that child’s arrival.
A study that appeared in The Journal of the American Medical Association in 2004 looked at whether people die soon after a milestone. In it, the authors analyzed death certificates from more than 300,000 people dying with cancer in Ohio from 1989 to 2000, and whether those people were more likely to die immediately after a birthday, Christmas or Thanksgiving. It turns out that these people were no more likely to die after these events than before, and the authors concluded that cancer patients are not able to postpone their deaths to survive such significant occasions.
The study was misguided, though: the authors asked the wrong question. The last time I looked forward to a birthday was half a lifetime ago when, for the first time, I could walk proudly into a bar without having to proffer my grungy fake I.D. And while I enjoy holidays, what motivates me to brave the traffic on I-80 with a car full of children and a DVD player on the fritz is not my enduring respect for pilgrims; it is the chance to be with the family I see far too infrequently.
“The weekend before the wedding was a close call,” my patient said. “I couldn’t move my leg or my arm, and that CT scan showed the lung cancer in my brain….” he trailed off.
“But that pill you prescribed really did the trick,” his wife picked up. “He could walk again after a few days.”
“Even if it hadn’t, if I’d had to tape my arm to my body and walk with a splint, I wouldn’t have missed it,” my patient said with a fierce look in his eyes.
I wanted to hang on to the photo, it represented such determination, but reluctantly handed it back. I said my goodbyes to them in clinic, then headed to the workroom, where one of the leukemia nurses approached me.
“When do you want to see him again — in four weeks or in five?” the nurse asked. I had the hardest time answering, and she gave me a knowing smile, understanding why I was hesitating.
“I don’t think it makes a difference, now that his granddaughter is married,” I answered.
He did come to clinic, just one more time. He was wearing a sweatshirt with the wedding photo silkscreened on the front, and underneath the caption, “Mission Accomplished.”
