Most oncologists get phone calls from relatives or friends about someone who has been diagnosed with cancer. Trying to be helpful, they suggest the friend or relative contact "my cousin (or uncle or classmate), the oncologist" for advice. They call and typically, we are told a sketchy story with so little information that we cannot provide even superficial comments or advice. The call often ends with our saying, "she is in good hands," or "he lives very near to (I name a good cancer program) if he wants another opinion." On occasion, we get more detailed information and face the difficult task of offering counsel without destroying the patient's confidence in the attending physician.
Less often in my own experience, my relative or friend passes on a request that I speak with the patient or spouse of the patient. These patients almost always have widespread cancer unresponsive to therapy. If it is clear from the discussion that the patient seems to be in good hands and that critical decisions must be made among difficult choices, I always honor the request.
First, what the patient or spouse (with the patient listening) asks is whether there is any other treatment out there that could help. But there is an unspoken understanding that their question also concerns the imminence of death and what course they should take. This is hard to do on the phone, some would say foolhardy. But if it seems right from what I have learned and the rapport is appropriate, I tell them what I think. Sometimes this means recommending the patient get his affairs in order, arrange for management to relieve pain or other problems, consider hospice care, and spend as much time at home with family as possible. In effect, I often confirm what their doctors had said, that the patient would die in the not-too-distant future.
The art of telling someone they will die does not come naturally. It requires confidence and experience and wisdom. I cannot explain these qualities with sufficient clarity to help someone else do it. The approach is sui generis, adapted to the teller's and the recipient's character, knowledge, and personality. It never gets easier…in fact, it may become harder as one ages.
Having to relate this opinion, and having done it all too often in my first years as a pediatric oncologist, has led me to read a great deal about death and dying over the years and to this day.
Unavoidably, it causes me to think about my own mortality. Philosophers, theologians, psychologists, and novelists have written reams about death. Many try to rationalize death in some way. They and I are looking for solace or some mechanism for facing the death of a patient or relative or friend or oneself.
I have found some understanding and a dash of comfort from these sources, but I am most touched by the poets who can, in a few words, contain volumes about the human condition, death being an integral part. The poet's oblique and figurative approach to the subject sometimes makes much more sense than the direct and rational. Here are two poems on the subject by Billy Collins, of whom I am an avid fan; he is a former Poet Laureate of America.
Is Death miles away from this house,
reaching for a window in Cincinnati
or breathing down the neck of a lost hiker
in British Columbia?
Is he too busy making arrangements,
tampering with air brakes,
scattering cancer cells like seeds,
loosening the wooden beams of roller coasters
to bother with my hidden cottage
that visitors find so hard to find?
Or is he stepping from a black car
parked at the dark end of the lane,
shaking open the familiar cloak,
its hood raised like the head of a crow,
and removing the scythe from the trunk?
Did you have any trouble with the directions?
I will ask, as I start talking my way out of this.
Collins thinks about death and with a few strokes describes the human condition and the mystery, apparent randomness, and loneliness of death. He wrote another poem about death inspired by a quote by Juan Ramón Jiménez: "The worst thing about death must be the first night." He explores the mystery of death and the feebleness of our ability to imagine or describe it with our catalogue of words.
before I opened you, Jiménez,
it never occurred to me that day and night
would continue to circle each other in the ring of death,
but now you have me wondering
if there will also be a sun and a moon
and will the dead gather to watch them rise and set
then repair, each soul alone,
to some ghastly equivalent of bed.
Or will the first night be the only night,
a darkness for which we have no other name?
How feeble our vocabulary in the face of death,
how impossible to write it down.
This is where language would stop,
the horse we have ridden all our lives
nearing the edge of a dizzying cliff.
The word that was in the beginning
and the word that was made flesh—
those and all the other words will cease.
Even now, reading you on this trellised porch,
how can I describe a sun that will shine after death?
But it is enough to frighten me
into paying more attention to the world's day—moon,
to sunlight bright on water
or fragmented in a grove of trees,
and to look more closely here at these small leaves,
these sentinel thorns,
whose employment is to guard the rose.
Finally, after puzzling over what is beyond death and the futility of words to describe that mystery, he returns in the last three stanzas to earth to focus on what he can appreciate that is here, the beauty and the mysteries that are closer to home. A good lesson for me, too.