“You know I am going to beat this.”
“No, you aren’t,” I think despondently.
“With a positive attitude and determination,” he adds.
“Then you’d be the first,” I silently retort.
A successful retired engineer, he is one of those who don’t fall ill until catastrophe strikes.
He had gone to the doctor feeling vaguely unwell and inherited a cancer diagnosis, and with it, an endless series of investigations. For a while, his surgeon sat on the fence – although the primary abdominal cancer was technically operable he had a hunch that the tiny, indeterminate nodules on the lung represented metastases.
“Why won’t my surgeon operate?”
“Because he doesn’t think he can cure you.”
“Do you think he is being too cautious?”
“No, I think he is looking after your best interests.”
His dogged determination refuses to consider the nuances I keep putting forward.
“I’ll do everything in my capacity to help you,” I say.
“I know you will. We’ll beat this together.”
“We may not be able to,” I respond, running away from the battle metaphor.
Unlike other patients, he doesn’t question my judgment or warn me off discussing bad news. He isn’t aggressive or demanding, in fact the opposite. Being a logical man, he doesn’t believe in miracles. But he just has an unshakeable belief that I am his companion in the fight of his lifetime and with me on his side, he can win.
I look across the desk at my well-dressed, thoroughly organised, thoughtfully spoken, impeccably mannered patient and ask myself how I am going to convince him that he has months to live.
I look at his wife searchingly. How does she regard his maniacal self-belief?
He starts chemotherapy and the remarkable response surprises everyone. Moreover, he suffers none of the anticipated toxicities, prompting him to grin, “Are you sure it’s not placebo you’re giving me?” Patients ask this from time to time, belying a real fear that their doctor has given up, so I answer seriously, “I promise you, I am treating you with the most intensive cocktail available.”

“Then why am I not sick?”
“Isn’t that great?”
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“We will overcome this!”
I look at his wife searchingly.

 How does she regard his maniacal self-belief? Will she help me inject reason into the conversation? But she doesn’t utter a word, as if reminding me that the doctor-patient relationship is between me and her husband.
The surgeon calls me to say that he has finally ruled out the prospect of surgery. “He does realise he is having palliative chemo, right?” The surgeon’s mild exasperation mingles with mine, threatening to overflow at the next visit.
As I take a minute to collect my thoughts, I find myself wishing that my patient would say just once, “Yes, I understand I have an incurable disease.” We don’t have to talk about prognosis, compare patients, or dwell on anything other than how great he feels but the acknowledgement would take a burden off my shoulders.
As these thoughts toss through my mind, my vague discomfort suddenly finds form in a single question, as if posed by an outside observer who is fed up of my attitude.
“Why does his relentless optimism bother you so much?”
I answer my invisible interlocutor with gusto.
“It bothers me because it makes me feel like I haven’t sufficiently explained things to him and maybe, he has taken my silence to mean assent.
It bothers me that one day, when his disease inevitably progresses, he will blame me for concealing the truth. It bothers me that his death will be fraught because how will we cross over from joking about placebo to accepting mortality?”
The invisible interlocutor retorts, “But how you deal with your fear and conflict isn’t your patient’s responsibility.”

Stung by the realisation, I face my patient again.
“I’m determined to beat this,” he repeats.
“You know what, that would be truly wonderful,” I answer with a smile, suppressing all my dread and discomfort.
Something in me relents and something in him revels. The next few months are blissful, devoid of rancour and competition. He directs the conversation; I lose the urgency to say anything to tip our fragile balance. When I feel a stab of anxiety about the future, I remind myself that my greatest value to him may be in not undermining hope.
To sustain hope while preserving honesty – this is the greatest challenge in oncology.
Oncologists attract much disdain from other doctors and patients for withholding bad news, twisting facts and distracting patients from dying well. Studies show that the majority of patients with advanced cancer don’t know that their life is limited and that treatment is not curative.
Other studies highlight the anxiety and distress faced by patients and their carers when there is confusion surrounding the future and when oncologists don’t play a role in helping shed the uncertainty.
But just like cancer represents many different diseases, cancer patients represent many different kinds of people, each with their own needs, longings and expectations.
To address them all in one tone would be as pointless as treating all cancers with one drug. Grief has no arc.
Just as I’d feared all along, the cheer dissipates but what takes away my breath is how quickly it happens. One week he is well and the next week he’s glowing yellow with liver failure and in pain. I am dismayed.
“I can do a scan if you want but clearly things look worse.”
I brace myself for the onslaught of protest with a reminder that this is the price of the preceding months of bonhomie.
But I am wrong again. He regards the numbers, looks at me, and says as calmly as if discussing the weather, “So this is it, then?”
Tears prick my eyes. Looking at his pale face and sleepless eyes, I yearn to have his old, ebullient self back, the self that wanted to challenge nature itself. I am tempted to lend him some of his hope back but all I can muster is, “I am really sorry.”
He sits there for a while, his face a kaleidoscope of emotions.  “I can’t thank you enough for the way you have held me up,” he finally says. “I’ve always appreciated your honesty.”
He’s got the wrong person in mind, I think dully as I recount my endless quest to save him from his delusions. His humility astounds me, giving rise to a tide of
frustration at yet another death at the hands of some invisible, unrelenting process that neither my patient understood nor I could genuinely explain.
The next week, at an unscheduled visit, he looks terrible.
As I write a morphine prescription, he mentions he is pleased to have the beehives sorted.
“What beehives?” I ask, wondering what else I don’t know about him.
“If I can manage the travel, I’ll show you.” He hesitates, then hugs me. I know I won’t see him again.
Defying progressive symptoms, he assiduously ties up loose ends and gives away various
belongings.
Then, he surprises me one last time by making a final trip to hospital.
I stare at the gleaming jars of honey, pale gold, painstakingly decorated and wrapped, finally understanding just how hard he must have worked to finish the intricate undertaking.
It turns out only one of us was in denial and it wasn’t the patient.

Source: The Guardian