By the time most people read this, the funeral of my longest-living patient will probably be over.
We first met when I was pregnant and she found out she had cancer. You might think that the juxtaposition of life and death discomfits patients, but children make for a happy point of connection.
Children entered our lives together. As I figured out motherhood, she began caring for a grandchild whose mother was unwell. Cancer on one hand, full-time parenting (as a grandparent) on the other. Without complaining, she took both in her stride.
Things worsened all at once. Her cancer progressed and the grandchild needed permanent care. She had no choice but to develop a singular focus to her visits: to stay alive for him. She loved him with a burning intensity that made her eyes shine and her voice quiver at the thought that he could be left without her.
This expectation sat heavily on my shoulders, and I suspect it’s exactly how she wanted it: for me to know that the welfare of a small child depended on my every move. As her illness advanced, I read more, listened more, and worried more. I needed to keep her alive and well.
To fetch her from the waiting room was a treat – a petite woman tucked away in a corner, wearing simple but marvellous clothes. Never on her phone, sometimes with a book but often content to watch the human traffic of a cancer clinic as if she had nowhere else to be.
Her interest in the outside world made for memorable conversations.
Over the years, we talked books, fashion and friends. She taught me quietly about the sacrifices of parenting. For the last few years, I told her that I admired her dignity and courage in the face of a terminal illness.
In her most vulnerable moments, when she couldn’t catch her breath, she expressed a fear – not of dying itself but physically suffering. For this she proposed that just as she trusted me with her life, I needed to ensure her peaceful death. All these years, I have carried this responsibility apprehensively, knowing full well how poorly end-of-life care unfolds for far too many patients.
When the evolutionary biologist Stephen Jay Gould was diagnosed with cancer, his oncologist said not to read the literature (which he did immediately) to discover that the median survival for peritoneal mesothelioma was eight months. Three years later, he penned a striking essay titled The Median Isn’t the Message in which he explained that statistical averages are at best abstractions that do not account for reality.
Twenty productive years after his first diagnosis, Gould died from a different cancer. When it comes to prognosis, I know what he meant by invoking “our actual world of variation, shadings and continua”.
When my patient’s cancer returned, she was given five years. Five stretched to seven, and then 10, and then she was a statistical anomaly. This was gratifying enough, but of course, something else was unfolding in parallel. Each year that she lived, her grandchild grew a year older. The baby learned to walk and talk, tie his own shoelaces and go to school.
My days contain memorable patients but I have seldom met one more composed. Over many hundreds of hospital visits, I met her husband once and her grandchild never. She came alone to receive good news, bad news and awful news, explaining that her husband had his hands full at home.
The last nine months saw diminishing opportunities for meaningful interventions. The cancer became obstinate, thumbing its nose at every idea I had. In one of our last conversations, she asked if it was better to receive chemotherapy or spend her remaining days with her grandchild. By this time, she was frail, weak and easily breathless. That she entrusted me with such a consequential decision felt both onerous and moving.
We discussed the notion of time toxicity, and she decided that if she couldn’t live longer the next best thing was to live better.
Her absence from clinic was palpable, so I set a weekly reminder to call her. She was surprised and delighted that our whole team still thought about her, and even when speaking became hard, she graciously thanked me.
***
Last week, her husband answers her phone, my greeting stuck in my throat.
The silence feels interminable before he tells me that she died peacefully after becoming unconscious. Somehow, I had never thought of this day as possible.
He adds the usual nice things that decent people do, but what I treasure most is her observation that our relationship never felt transactional. In a place where every consultation feels hurried and the price of failure is high, this posthumous tribute feels as magnanimous as she was in life.
Her funeral coincides with my clinic. I fear that I might not make it in time. Sometimes they read my columns together, he says; I ask if I can write one in her memory. Yes, he laughs, provided I can read it to her at her funeral.
I write late into the night and the editorial team delivers the rest. I work with humane people.
I am hoping to be at the funeral to say a final goodbye from our whole team. But if not, she would laugh forgivingly that in my place, I sent a column.
Ranjana Srivastava is an Australian oncologist, award-winning author and Fulbright scholar. Her latest book is called A Better Death
