Two goodbyes

From a brightly lit hallway in a shared clinic space, I enter the examination room and see Vince, a 50-year-old man who has completed multimodality treatment for gastric cancer. As I enter the room, I am greeted with a warm smile in his twinkling eyes, his mouth hidden by a mask. When I operated on him five years ago, his surgical pathology showed high-risk features, but thankfully he remains disease-free.

I have been looking forward to seeing Vince in person today. I journey with patients through the ups and downs of surgery, adjuvant treatment and surveillance, getting to know their interests, oddities, hopes, fears, families. I hear of their children and grandchildren, the trips to the cottage, foods that cause them trouble, their bowel habits, the death of the family pet, home renovations and plans for retirement. Vince is no exception. When the surveillance interval comes to a close, I find myself feeling somewhat uneasy. How do I say goodbye?

The last surveillance visit is mostly social, hearing about families and plans for the future. “My daughter is starting university and I am so happy that I am around to be a part of this!” Some general questions about symptoms — eating, bowels, pain, weight, energy — no concerns. A quick physical exam. Then a review of imaging and bloodwork. “It all looks good, Vince. No evidence of recurrence.” Now what?

Vince says, jokingly, “I hope I never see you again because if I do, it means I’m in trouble!” This is followed by words of gratitude. “Thank you for everything you have done.”

“Thanks, Vince. It’s been my pleasure and I’m happy you’ve done so well. So long … ” An awkward silence follows.

So long?

What about “Good luck?” “Great knowing you?” “Have a nice life?” “All the best?” “See you around?” None of these seem quite right. I haven’t come up with a good phrase.

Then comes the recurrence. Six months after this awkward goodbye, I receive a call from a physician at another hospital telling me that Vince has been admitted with severe abdominal pain and early satiety. “Can you look at the imaging?” he asks. I do. It’s not clear what is going on but, immediately, I arrange for transfer to our hospital.

I try to hide my concern when I see him. He looks thinner than when I last saw him and his skin looks sallow. His eyes are wide with questions and fear. “Hi Vince,” I say. “What’s been going on?” He tells me his pain is back. We each know what the other is thinking. I examine his distended abdomen. Is that a fluid wave?

We move ahead with a diagnostic laparoscopy and he is full of peritoneal nodules and ascites. I perform biopsies but I know what this is. My heart sinks. How will I tell him?

I have a discussion with Vince and his wife after surgery. It is devastating news to deliver, but I have learned that patients generally know when something is wrong. His wife is quiet, sitting on the chair at the bedside, holding his hand and looking down at the floor. What must be going through her mind? I take his other hand. “Vince, this is not curable.” I pause for what seems like a long time. Through the nearby window, I see an ambulance rushing down the street toward the emergency department, lights flashing, carrying another person whose life has been changed by illness or accident. “I would suggest we get Palliative Care involved to help with your pain and we get you home. I can’t offer any surgery. I can send you back to Medical Oncology to discuss more chemotherapy.”

Vince went home two days later after seeing a palliative care specialist and a medical oncologist. His pain was controlled better, and he had decided against chemotherapy. This was a familiar scenario; some of my patients choose to undergo palliative treatment while others do not.

The morning of his discharge was beautifully sunny, and he sat by the window, taking it in. His wife had not yet arrived. “So, you ready to go?” I asked, searching his face for emotion.

“I’m going to spend time with my family. When I feel better, I think I’m going to take the kids and go back home to say goodbye to everyone. I know I won’t see you again, but I want to say thank you.”

“Vince, I want to see you again. If you can’t come in person, we can chat over the phone.” I am not ready to say goodbye. The emotions build up inside me as I process the injustice and finality of his situation. For him to go through all that treatment, only to have it end like this? We chat two weeks later, and his symptoms are progressing. No appetite, more weight loss, pain, fatigue and constipation. The palliative care team is adjusting his medications. “Let’s chat again in a few weeks … ”

I know end of life is near when I find “no shows” for visits with providers on the electronic medical system. Does anyone wonder if the “no show” is because of car trouble or whether it is because Vince is dying? I feel compelled to call.

“Hi. How’s Vince doing? I know things must be difficult.” There is a pause. I can hear someone crying softly in the background.

“Vince wants to talk to you. I’ll put the phone up to his ear.” Some rustling of blankets and movement. A tired voice whispers “Hello.” His mouth is dry, his voice low and weak.

“Hi Vince,” I clear my throat and try to sound slightly cheerful.

“I’m so happy you called. I’m dying now. The family is here together.” Such an effort to say these words.

“Vince, I’m sorry we couldn’t do more,” I reply, choosing my words carefully and trying to swallow the lump in my throat.

“You did everything. I want to say goodbye and thank you …” The words are authentic and deeply touching. His voice trails off. I can hear his wife crying nearby.

“Goodbye Vince. I’m praying for you and your family. Take care and …” my voice cracks. And what? Reminded very briefly of the first time I said goodbye to him, I find myself struggling to say goodbye again.

A career in medicine is full of goodbyes. Some are happy and hopeful, and others are crushing. It is hard to say goodbye, whether to someone who is cured of cancer or someone who has succumbed to it. Because as much as I become a part of my patient’s life, they and their families become a part of mine. I said goodbye twice to Vince, but many goodbyes with other patients are yet to come. Some will be for those moving on with life, and others for those journeying down an unknown path where no one can follow. After many goodbyes, I have accepted that emotions will be present and help me and my patients give appropriate credit to the moment and what it stands for.