But we hadn't counted on Tom, Dana's hard-charging husband. Tom seemed to believe that he could bend the universe to his will if only he pushed hard enough. In family meetings he did the talking while Dana stayed quiet. Tom advocated continued aggressive care -- more chemo, transfusions to help with anemia and bleeding, radiation treatments -- when it seemed to us that Dana just wanted to stop. It was Tom who recited the list of milestones that Dana had achieved -- getting to attend her daughter's wedding, celebrating a birthday, moving into a new home. She had lived for several months longer than we'd believed possible. None of us were sure that Dana thought achieving the milestones had been worth it. But it was hard to find time to talk with her alone. Tom was a constant presence at the bedside.
Dana lived for much of her last six months in hospitals, spending three months in an inpatient bed at one point without a break. Many days were spent negotiating with Tom, who wanted to blame Dana's weakness on anything -- the drugs, inadequate nursing, the food -- anything but the terrible cancer that was taking his wife's life.
"Am I dying?" is a question a hospice doctor hears a lot. There's no border crossing, no checkpoint, no security screening that demarcates the beginning of the Land of the Dying. One often can only know the answer to the question in retrospect. Certainly from Tom's perspective, his wife was not dying until the very end.
But the end came eventually when Dana was admitted to our palliative care floor for the last time. Tom was still talking about radiation and more chemo, but this time Dana stopped him. She'd had enough, she said, and there would be no more. We focused on comfort -- although Tom still requested, and got, more lab tests and a transfusion just a day before Dana died. And we had endless discussions with Tom about exactly how much pain medicine we could give, because he believed the drugs, and not the cancer, bore responsibility for his wife's decline.
Late one Friday afternoon, I quietly entered Dana's room. She was unresponsive and ashen. I knew from her breathing that her life expectancy could be measured in minutes. Tom was sitting by the bed, stroking Dana's face and holding her hand, his back toward me. Another family member acknowledged my presence with a nod. The atmosphere was so charged, the room so still, that I was afraid to breathe loudly, let alone speak. After perhaps five or ten minutes, the family member said, "The doctor's here, Tom. Do you want to ask him anything?"
A long minute passed, and Tom asked, "Does he have a cure?"
My heart burst open. I had to work to prevent my knees from buckling. And then I looked at Dana. She was gone. I put my stethoscope on her lifeless chest, and Tom -- the man who'd shown no pain, who'd demonstrated nothing but a fierce determination to surmount his wife's cancer -- Tom began to weep.
And I found my inner self rejoicing just a little bit. Not over the death of a brave woman, and not over a husband's pain. But the fact that pain could be expressed, that anguish could be seen -- that seemed cause for quiet celebration. Tom was unlikely to ever be able to heal without taking the first, tentative step of acknowledging his loss and his suffering. I hope he can remain open to the feelings he finally let us see.
And as for me, I know I have to let my heart break over and over again, as I encounter the Toms and the Danas of this world and try to guide them through the Land of the Dying.