1. Three Lessons
I came back to the hospital after office hours just to tell Seana the operative findings.
As her general internist, I knew there was no real need for me to tell her, as she would be just coming out of general anesthesia and was, technically, on the surgery service.
But I felt that I should. This would be her fourth major surgery to try and defeat the inexorably metastasizing colon cancer. Each surgery and course of chemotherapy had bought some time, but this one was being done she was only 48 years old. The oncology surgeon, a perfectionist, was also a marathon runner, and this surgery came more from that state of mind than from one of genuine hope. This had been one patient for who we had all been going the extra mile.
The surgery was brief: open, look, close. Cancer was everywhere: inoperable.
I suspect that I also came back because I didn’t want some surgical resident during sign – out rounds to casually mention how extensive her tumor was, and leave to answer a page. Seana was strong, and a realist, but still, she had hopes.
This wasn’t going to be easy.
Into the partially darkened room I walked, quietly closing the door behind me. Seana was awake, though clearly somewhat mellowed by anesthesia and pain medications. She asked how it went: I told her. We sat, and held hands: she cried. She then began to tell me about her first husband, the love of her life, who had died of leukemia six months after their marriage, 20 twenty years before. She told me of the strength she gained when she thought of him. She had approached his death with a spirit of adventure, saying he was going to look up famous people in the afterlife. She laughingly said that this mostly consisted of people he had seen on Jeopardy. Then she described the secret image she used when feeling overwhelmed or frightened: an image of him lying on his back and lying face down on top of him, melting into him; an image transcending even sexual union.
I listened in shock and amazement. Only a few hours before, a patient I barely knew had died. He was a man in his late 30’s who had come home from a business trip with a severe headache. I had spoken with him and his wife on the telephone and instructed her to bring him to the emergency department. Soon after he arrived, he became unconscious, suffering an intracerebral hemorrhage, which was quickly determined to be due to underlying acute promyelocytic leukemia. For four days and nights, he was treated by a platoon of specialists, to no avail. We had twice-daily family meetings. He died in the ICU, leaving behind his wife, two young children, his parents and numerous family and friends in the waiting area.
After his death, his wife had wanted to be alone with him, and she was shown to his room. All the leads, tubes, wires and monitors had been disconnected and removed. She climbed onto the ICU bed and lay on top of him. It was the precise scene that Seana had described. I don’t know how long this lasted, but in the rapid-paced intensive care unit, it seemed like a very long time. It was primal and ancient and cut through all the technologic barriers we put between ourselves and death, transcending clock time.
Unsure whether this woman’s action was “healthy”, someone asked, “How long do we let this go on?” A nurse replied, “As long as she wants.” Though Seana was describing the same thing, I realized she was telling me this only because all her defense mechanisms were down. I felt privileged to have heard this, to discover a little of the source of her inner strength. I wondered if this new young widow of a few hours would also get this strength inscribed into her memory.
Later I read of the ancient Egyptian myth of Isis and Osiris, where Isis reassembles the bones of her slain husband Osiris and lies over them, restoring him to a kind of life. He becomes ruler of the Underworld, the next world, the world we enter through the doorway of death.
It had a familiar ring.
It was a poignant moment.
As I sat at Seana’s bedside in the inpatient hospice unit, the end seemed near: maybe that day, maybe a few days. However, she was comfortable with octreotide and Dilaudid drips, which controlled the pain and the vomiting of her bowel obstruction; we could finally talk of something other than physical symptoms. I had cared for her during the past 3 ½ years, battling this disease with all that the oncologists could offer. Once quite striking, but now bald and sporting wire rimmed glasses, she resembled an emaciated Gandhi. And remarkably, like Gandhi, she never complained; to the end she remained one of the most grateful, open and selfless people I have ever met.
Moved, I spoke spontaneously from my heart. I was outside the “medical model,” but not so far out from a patient who was then clutching a large crucifix to her chest; indeed, it was one the crucifixes that Joseph Cardinal Bernadin himself had blessed as he lay dying of pancreatic cancer the year before. I told her that the body was only house for the soul and it would soon be time to vacate the house. I went on in this vein, elaborating partly because I wasn’t entirely sure she was understanding me and partly because I was caught up in the feeling myself. Then—silence. We sat together for what seemed a very long time. I had no idea what it meant. Was she thinking, or asleep, or was she—perhaps moved by my words—about to die?
She finally broke the silence. “Oh, Dr. Magrisso, I wish what you said were true, but I just don’t know.” It was both deflating and grounding. For I had to confess, I didn’t know either.
We just sat there, two souls in front of the great mystery, in awe of the unknown, both uncomfortable with the idea of death.
But we were not alone either, for there was a presence in the room. Subjective, and immeasurable to be sure, I sensed the presence of countless millions throughout the ages who have had similar deathbed discussions. It was mixture of vulnerability, consolation, fear and wonder.
And in the sacredness of just being together, in that silence, none of the struggles between faith and doubt really mattered anymore.
Seana lived in the inpatient hospice unit for more than a month, far longer than anyone would have predicted, sustained only on pain medications and Popsicles.
Late March in Chicago is only technically spring. Most of the time it is still cold and overcast. However, this day is warm, 60 degrees and sunny. It is a Saturday and we planned to go outside after I finished rounds. I found Seana in the back on the unit sitting in her wheelchair, IV pole and pumps in tow, her winter coat partially covering her hospital gown. Her sister-in-law and Carla, her nurse’s aide, are ready to go. Everyone is in a great mood.
We go down the elevator, into the brightly sunlit outdoors, and onto the driveway by the women’s hospital. Though the idea is to just sit in the sun a bit, we are drawn toward the sidewalk. The usual smokers are outside the hospital and the smell of their smoke is the first thing I notice. It seems horrible to come out here, to have that smoke greet Seana. Simultaneous with my thought, though, she says, “What a wonderful smell!” I ask her what smell was so wonderful and she replies that it smelled like McDonald’s. I am thinking, she really does appreciate everything. We go on to the sidewalk and watch a father pitching a ball to his four-year-old son. The continuity between generations is moving, almost beyond words. As we go to the corner, an inspiration comes: we could make to Lake Michigan, only a few blocks away. Does she want to try? Does everyone want to try? Of course we do! Carla says that it felt like we are cutting school. So off we go, across Sheridan Road, the four of us quite a motley sight: Seana looking like death warmed over in her wheelchair, I wearing my gray hospital coat, the nurse’s aid in an outrageous green leather coat, her sister- in- law in an Ohio State sweatshirt. Cars slow down; we wave. We walk up the road to the beach, cutting through rutted lawns, the wheelchair bumping in the spring mud. Seana doesn’t say much, but she seems translucent in the sun, beaming, lit from within. I imagine it as her farewell tour of the world. I can only fathom the poignant wealth of feelings she experiences. For me, it evokes the sense of being a tourist, where everything seems special, a little strange, and very impermanent. I have experienced the same lakefront that way three years before. Then, I had just recovered from my own near death in the form of a myocardial infarction and cardiac arrest and was filled with joy and gratitude that I was still here. The world looked new.
I had been Seana’s age.
She taught me that awareness of death and appreciation of life go together: to imagine that you are seeing things for the last time has the same intensity as seeing them for the first time.