Valley of the Shadow

I don't know a specialty in medicine more difficult on the emotions than oncology. There is something about cancer, the disease and its effects on people, that is simply so wearing. Hope is persistently grasped for, undermined, needing to be re-defined. Almost all encouraging words are qualified, tentative, temporary. Light in the darkness can often seem a dim bulb indeed.

Every oncologist I know is a warrior. Every one fights for their patients and against the disease with a determination and ferocity of greater-than-themselves proportions. And it is for oncologists this battle on two fronts. On the one hand, against the disease, against the cellular madness that is cancer, the terror cancer creates. Oncologists know first hand about the personal "war on terror" going on in their patients. Which is why on the other hand they are fighting for their patients, "for" both in the sense of "on behalf of...," and in the sense of "continually to preserve the personhood of..." as the disease tends to reduce people to their diagnosis. They tend to become what they "have," and lose who they are. The oncologists I know strive to keep hold of the person, to support them in being who they are, even as they fight with them against what they have, that which would rob them of who they are.

Some oncologists do better at battling the disease than saving the personhood of the person. And really, who can fault them? The disease if often more real to them than to the patient. The numbers, the pathology reports, the CAT scans and MRIs-- these can seem abstract to the patient, but this is how the oncologist comes to know the Enemy and Its activity. They are intelligence reports. They are measures, of success, of progress, and for some, even of failure. This is medicine at its most modern.

There is a price paid by oncologists who balance their disease-fighting with their patient care. When it comes to fighting just the disease, oncologists lose many battles, even when they more than occasionally win a war. But when it comes to patient-care, it isn't a "battle" which is lost, but a person, or a part of a person-- an organ, or a capacity, or dimunition of spirit, and sometimes a life altogether. There is a lot of grief experienced by oncologists.

How well do oncologists grieve? Well, it depends on the doctor of course, on the quality of the physician's person, on their character, on their emotional make-up. But basically, most oncologists grieve like the warriors they are-- meaning not well. Grief does not become a warrior.

Nor does discouragement. Sitting in an oncologist's office and watching the parade of people, each engaged in their own struggles and experiencing whatever degree of challenge to their vitality and their life that they are, I imagine what it would be like to spend my days facing this seemingly endless line, looking into their faces, searching for the light in their eyes, listening, listening, listening-- and working to find the right words of response, the right shadings, so that the greys are distinguished, and even might display of promise of becoming vivid. I can scarcely imagine anything more exhausting.

Yet, oncologists are among the most caring people I know! Whence comes their Heart?

Well, for one thing, oncologists have what I believe to be a rare ability to gather and store encouragement. So whether it be from an improvement in the numbers or an "observable" decrease in the size of a tumor, or whether it be from a shift in a patient's attitude or a word of appreciation, oncologists vaccuum up these bits and pieces and cultivate them. They make large whatever evidence of encouragement there might be.

And for another, I believe that oncologists have the even more rare spiritual ability not to fear Evil. They walk ever and constantly through the Valley of the Shadow, sometimes the Shadow of Illness, sometimes the Shadow of Death. And while they might face fears, their own and those of their patients and their families, it seems to me that they do not fear Evil. Cancer has its own morality; when it invades us, we discover more about our own. It would be easy to see cancer as Evil incarnate, in its mindless, relentless assault. Even so, oncologists do not fear It. In fact, they fear little-- or so it seems to me. (Whatever their fears are, they keep them to themselves!)

But the fear of Evil is particularly insidious because it undermines one's determination to do all one can, to utilize every resource, even to do to another what under other circumstances would be unthinkable or repugnant. To be an effective oncologist, one must be at peace with one's own capacity for evil, and indeed unafraid of the ways Evil is made manifest period. In my estimation, the oncologists I know evidence this capacity.

Knowing as I do that oncologists, like the rest of us, may or may not believe in God or even a Higher Power of their own definition, I have come to believe that nonetheless, the "rod and staff" of the Divine provides their own comfort. For the Source pours out comfort and peace on all-- even those who may not acknowledge the Source.

And in the end, it does not matter that the Source be acknowledged, least of all to the Source Itself! It matters only that oncologists continue to fight the good fights that they do-- and that we appreciate them for their dedication, their determination and their great Heart.

Love and Fear

The aged teach me so much about living every day. Contrasting lessons give me more to consider as I make choices that determine how I am to live, in a way, with one eye on the day, and another on the night, on the end of my own life.

So I'm visiting this couple; they've been married a long time, maybe 40 years or more. They are in their late 70's now. They have no children of their own, but she has, from a previous marriage, and they are distant. Not a wide social circle. I get the feeling that they've had basically only each other for a long time.

They sit apart, on opposite ends of a long sofa, as if thrown like pillows into each of the corners. I sit across from them, on a kitchen chair I've brought into the middle of the room. I wonder about this decision: Am I sitting too close to them? Are they more comfortable with distance.

We are talking about the impact that his learning he has a terminal prognosis has had on their relationship. She worries about the threatened rigors of caregiving. She is a small, slight woman; he, a tall, medium set man. She's right: doing anything too physical would be difficult for her. He worries about becoming increasingly dependent. This is not a lack of confidence in her skills, as much as it is a humiliating erosion in his dignity. He says, "I can't even pull my own pants up now as it is." They both know it is going to get worse this way.

Yet he says, "I hope I live another two years." (It strikes me how people choose an arbitrary number in their hope to live with a terminal prognosis. Two years. What is two years? What would living two more years mean to him? I don't ask.) I just hear her say, "I hope I die before he does." Then she looks right at him and he looks at her, and she says, "I hope I die before you do." He looks pained, and helpless about that, too. It is one of the few times in our conversation they look at each other.

When I leave, I feel profoundly sad. It is a situation in which neither is really going to get what they want. Their fears, their dread, really, that this is what their lives have come to, fill up the space. (It always astounds me that people can live into their 70's and not consider that death is on their horizon.) Their home is very clean, very well-ordered, but their lives have become more disordered than they want to admit. The next world for each of them is growing under the surface, like the cancer that is taking his life. They can't see it, but it is there.

I can sense what is present, but I don't get a handle on what is missing until I visit another of my patients, a 91 y/o woman whose only slim, time-related hope is that she might live until 92 in October. She isn't tied to it; it is more like she wants to live out the year, complete it as it were. Instead what bubbles up within her is gratitude! The light is fading in her eyes, but it is warm, and she is thankful for a great deal. Our conversation turns to the reality of the dwindling numbers of her friends. When one is in one's 90's, one outlives a lot of people one knows-- and loves!

Among the latter is a man who died in his 90's a couple of years ago. They were dance partners. They enjoyed ballroom dancing, both the activity and the society around it. She says, "He said, 'let me call you sweetheart,' so I did! I let him call me 'sweetheart.'" Her eyes twinkle as she remembers, the romance of it still in her heart. I ask her, "Since he died, does anyone but your children say to you, 'I love you'?" She says, "No." We say a few words about what she misses about him being that: he was the last man to say to her, "I love you."

So I say to her, "I love you." She smiles warmly, her face brightened, and she says, "I love you, too." I say, "May I kiss you on the forehead?" She says, "Yes," and I do. We are both grateful for the moment.

When I leave her home, I realize that she has taught me something about the importance of having someone in our lives (besides our family members) to say to us, "I love you!" Not only does it brighten the moment, but her memory of having beeing told "I love you" sustains her days, and keeps alive the gratitude in her heart. It gives her a mooring for her wandering mind to drift to. She doesn't have to remember so far back!

And I remember the other couple: no "I love you's." Neither said, "I love you" to the other. I wondered how much an "I love you" might have dispelled their dread or been an antidote to their fears.

The Apostle Paul wrote that "perfect love casts out fear," but I realized that I do need love to be "perfect." I just need someone to say, "I love you" in whatever imperfect way it comes. And I want to be able to offer "I love you" to others, in my own imperfect way, too.

Mornings and Mournings

I awoke this morning feeling as if I were dangling over a well of sadness. Most mornings I am able to ingnore it, or the feeling passes too quickly to be noticed, or maybe I'm in a different place altogether, I don't know. But I have these mornings, too, when the sadness of others, the sadness I witness and wade through with them seeps into my own, and replenishes my internal aquifer as it were. This AM, I am aware of the sadness of the world, and my own.

I don't know that we are supposed to rid ourselves of this sadness. I've not tried to rid myself of mine. Instead I use it as a touch point between myself and others, a sea for empathy where sadness is acknowledged to be part of our common human condition. Maybe we all "dangle" over it in some way or another. Maybe events conspire, and we lose whatever it was that was holding us up and keeping us from plunging, and we find ourselves swimming or even in over our heads in sadness... I don't know.

I remember reading a book a long time ago by the Spanish existentialist Miquel de Unanumo, called The Tragic Sense of Life. I don't remember that de Unanumo talked much about sadness per se, but rather, like a lot of existentialists I suppose, about life's essentially tragic core. There is a truth to that perspective. Certainly in hospice and bereavement we encounter people who are discovering something of the tragic stream of life.

But tragedy is only one stream, and the River of Life is fed by many tributaries. My hope for people who discover the river of tragedy (suddenly) has made its course through their lives, is that they will continue to explore Life's ever changing landscape. There are mountains of gladness out there, too, still. It is just that everything has shifted for the time being.

I awoke this morning more aware of my sadness than anything, true. And really, it'd be alright to stay in this place for a while, for sadness after all is a part of life-- I am no less vital, I have not stopped living because I am sad! But the day beckons. The birds who come to the feeder cock their heads at me, as if pointing to other places to go, alternatives to staying put. I'll just have to follow them, and see where they are going...

Like the ol' spiritual said, "I'll fly away..."