We circled him with our impotent answers, our guarded gestures of help. Circled while the cancer waged its all-out assault, stripping him of vigor and hope.
Dick nodded in his bed during most of the family meeting, the one hastily convened before his hospital discharge. His wan, sunken eyes surveyed the jury: family doctor and oncologist; surgical and hospice nurse; wife and son. The diagnosis of pancreatic cancer was made weeks after he first voiced his vague complaints. The tumor had crouched in the shadow cast by other, more demanding diseases: diabetes, coronary artery disease, hypothyroidism, and cryptogenic cirrhosis of the liver. Now he clung to his hospital bed like a drowning man clinging to flotsam. Dick knew we couldn’t cure him. He demanded neither relief from pain nor lies about the length of time remaining. What, then, were his plaintive eyes looking for?
As a Catholic physician, I have always wrestled with the formulaic Christian answer to suffering: that it brings us closer to the pierced and abandoned Christ of the Cross. These words, of course, roll off most of my patients. And because my life is largely blessed, they don’t really register with my own experience. Yet in this identifiable figure of Christ lies the whole of humanity, a mankind for whom suffering insinuates to the core. It falls flatly, indiscriminately on both the innocent and self-abused, the hypervigilant and reckless, and on the elderly whose only crime is survival.
Last fall, after a heedless encounter with poison ivy, I suffered a severe and protracted case of dermatitis-a painful rash that covered my legs, groin, and underarms. As a favor to my wife, I spent a dozen nights on the sofa, bathing my limbs in jewelweed compresses and scratching my skin raw. Over the creeping hours, darkness poses a danger for the restless mind. The usual touchstones abandon you: the world is closed for business, resting before the next normal day; but you are not normal. You sense that there will be no normal tomorrow-not the next day, nor the next. And disease only accentuates the feeling of alienation, for it is itself an exile. The scourged join a brotherhood apart. We drift alone on an ocean far from kin and companion, scanning the shores for a place to beach our sinking ship but seeing only waves and unbroken horizon.
A bout with poison ivy is a miserable but trivial ordeal. Yet those sleepless nights provided a foretaste of the abandonment and self-doubt that plague the chronically and terminally ill. I could imagine losing the lifeline to the other me, the healthy, productive, autonomous me that one forfeits during illness. This is a primal challenge posed by life-altering disease, and even a physician-perhaps, sometimes, especially a physician-needs to be reminded what patients need to face it: not only competent care, but hope. Their challenge can be read in every dying person’s eyes.
What is the nature of the thing called hope? The ultra-marathon runner and author, Bernd Heinrich, cites the example of aboriginal long-distance hunters, who countered exhaustion by focusing on their prey’a saving way, Heinrich notes, “to keep in mind what is not before the eye.” The wisdom of an old Shaker song locates hope in accommodation, assuring us that “When true simplicity is gained / To bow and to bend we shan’t be ashamed. / To turn, turn will be our delight, / Till by turning, turning we come round right.” And the Czech playwright and politician, Vaclav Havel, observed that “hope is not the same as joy that things are going well, or willingness to invest in enterprises that are obviously headed for early success, but rather an ability to work for something because it is good, not just because it stands a chance to succeed.” Hope, then, encompasses vision, acceptance, and trust. It reflects the human drive to belong to a greater good, some deeper purpose or wider plan. The doctor knows that hope cannot be prescribed or dispensed; rather, it grows in the soil tilled over a patient’s lifetime.
On a Friday morning I made my first and final visit to Dick’s home. He lay on a cot in what had once been a small study. I spoke to him and, to my surprise, he mumbled a response through the twilight of morphine sedation and starvation ketosis. To his wife standing beside me, I indicated the ominous signs: lengthening periods of sleep; apneic breathing; mottled legs; a rattle rising from his emaciated chest.
We adjourned to the kitchen table where Dick’s son and parents had gathered. I listened to his father talk about the early years, how as a ten-year-old boy Dick had sought out part-time work on a neighbor’s dairy farm. He had been steadfast all his life-a model employee, a diligent son, later an equally diligent father and husband. Over the years that I had treated him as his physician, Dick asked only for honesty and a little of my time. And this in turn is how he, as a retail salesman, had treated his customers: with more listening than explaining, more helpfulness than hype.
It occurred to me that there is no luckier man than one who can die in the midst of the life he has created, surrounded by the people he loves, and I told his family so. “It’s obvious how much Dick loved you, and how generously you paid him back,” I said. For my own part, I regretted not having said this to Dick when he could still hear it. I thought of the many patients I have known who negotiated their dark nights on vapors of hope: hope to wear one’s wounds with dignity; hope to maintain direction and take solace in doing one’s diminishing part. Above the common calamity rise the reassuring words of Thomas Merton: “Sanctity does not consist in suffering. For the saint, suffering continues to be suffering, but it ceases to be an obstacle to his mission, or to his happiness, both of which are found positively and concretely in the will of God.” The occasion of Merton’s remarks was an essay on St. John of the Cross, a man whose life and story (Dark Night of the Soul) are synonymous with hope that embraces the depths of despair. Certainly hope is not the exclusive property of believers. Our faith merely gives us a leg up. We know that by doing the will of God we are destined to “come round right.”
Dick died before sunrise the following morning. It is often said that the dying prefer the small hours of the morning to take their final bow. The night seems well suited to separation, cleaving us naturally through our circadian rhythms and the earth’s rotation. It is’in the end-as natural a darkness as we may come to comprehend.
