On Being a Doll

Mrs. Soliz had been battling metastatic breast cancer for more than 4 years, and now suffered from severe headaches and seizures. She also fractured her left humerus after picking up a grocery bag. “I was coming from Sedano’s. I had bought three cans of ‘frijoles negros,’ El Ebro brand,” she recalled. “Y una bolsa de arroz blanco,” she continued in the language of Miami Cubans—Spanglish. I was trying to understand how the El Ebro brand of black beans would affect the weight of the bag—delicious, yes, but not any heavier than Goya or any of the other brands. The problem, of course, was not what she was carrying in her Sedano’s bag, but in her humerus. The most disheartening thing to me was that this inevitably happened despite a plethora of toxic therapies. She was now finishing up radiation to her left arm. Just 6 months ago, she was able to drive herself and walk around. Now the cancer had left her wheelchair bound, and doing even the simplest things was impossible. She needed her husband’s help to get up from the wheelchair or to get dressed or to bathe. She now weighed no more than 80 pounds. Her body had been conquered, by the “Emperor of All Maladies” [1], but it had not affected her spirit. It may have ground her body like a millstone, but she remained defiant. Her soul, her personality, and her mind had not ceded any ground. She was of the generation of Cuban women—like my own grandmother, “Mimi” —who embraced life, in all of its imperfections, with tenacity: two parts prior life experiences (especially the 1960 revolution, known by all Cubans of their generation as “el exilio”), two parts faith, one part Latin culture, and a dash of fatalistic humor. After many years of practice, it was clear to me that the will to live was a powerful force in its own right. Mrs. Soliz had yelled from the waiting area, in Spanish, “I need a doctor now!” Her husband had brought her an hour early, but, understandably, she did not want to wait. Her yelling prompted Sylvia, my nurse practitioner, to rush her into a room to avoid a scandal. Once Sylvia had seen Mrs. Soliz and we discussed her situation, it was clear to me that Mrs. Soliz, who had come for a second opinion, had reached the boundary of medical knowledge. Over the years, she had received multiple treatments—I counted 11—from her cancer doctor, but it was clear that all of that was behind her. What mattered now was to make sure she did not suffer in her final days. To some, this imaginary metaphorical cliff where medical knowledge ends and the unknown, or the divine, begins may seem like a place of utter darkness and pain. I had viewed this place with those same eyes when I started practicing oncology. I learned, through the process of bearing witness for my patients, to consider my role more as a guide. I felt like the boatman of Greek mythology, helpless to change course. Mrs. Soliz was lucid and rational. I asked her, “What are you hoping for or expecting out of your visit today?” She stared directly into my eyes for at least a minute before uttering a word, seemingly attempting to decipher my character. “Doctor, I don’t want to die, but I know that I am going to die soon, right?” she said. I replied with my usual explanation, which left me unsatisfied. “Unfortunately metastatic breast cancer is an incurable but treatable illness. Over time the cancer becomes more resistant to all the treatments until there reaches a point where it will continue to grow and take over, no matter what treatments we throw at it. The problem, of course, is that this battle happens in your body, so while the treatments may do nothing to the cancer, they can potentially harm you.” I paused to look at her and her husband. This time, I was the one attempting to decipher a deeper understanding of what they valued. In the early days of my practice, I was afraid of this frontier. With time and practice, I realized, mainly from patients like Mrs. Soliz, that there was no reason to fear the unknown. I started venturing more and more into this uncharted territory and walked alongside my patients to give them comfort and to bear witness, continuing to see them even after referring them to hospice. At first, these moments of bearing witness were filled with anxiety as I imagined what it must feel like for my patients. I also came to terms with my fear of mortality, which, now at 42, does not seem so remote as it did just 5 or 10 years ago. Through these explorations, I found I grew both spiritually and professionally. Venturing into this world is a humbling experience, but one also learns the art of silence and the value of faith. My comfort with these silent moments with patients has improved over the years. I thought of myself somewhat like a Buddhist master, since I could now tolerate long silences that would have driven others mad. But I realized at these interfaces—between life and death, between science and religion—that I wasn’t the one making the journey and that it was not about me. If a patient wanted silence, there was no need for me to fill the void with platitudes. I was now at that point with Mrs. Soliz and her husband. After what I had said, we shared a good 5 minutes of silence. She then acknowledged that she understood there were no other treatments left at this point. She thanked me for listening to her and for confirming what her oncologist of many years had told her. She asked, “Doctor, will there ever be a cure for this?” To answer this in a manner that was sensitive to the moment, I replied, “I don’t know, but I sure hope so.” She smiled in agreement with my response, and that was all the confirmation I needed that I had struck the right tone. I helped her husband put her back in the wheelchair to exit the exam room. She told me, “Doctor, your job is to hold my left arm still.” This was the arm that had been fractured by lifting a small grocery bag from Sedano’s supermarket. I was feeling pain myself touching her arm, and I think she could tell by my facial expressions. She reassured me in her Cuban Spanglish by saying, “No te precocupes, Doctorcito, it’s OK. Just don’t let me fall, cono!” Fortunately, the transition to her wheelchair went well. She thanked me and said that no doctor had ever helped her sit in her wheelchair. With her good arm, she tossed me her heating pad, which she used to alleviate her pain, and asked, “Doc, could you be a doll and zap this 3 minutes in your microwave?”