Canadian Family Physician April 2017, 63 (4) 306-307;

The deeper that sorrow carves into your being the more joy you can contain.
— Khalil Gibran, “On Joy and Sorrow”

Violet was a 64-year-old woman who became part of my practice when her family doctor retired. She was a rather unassuming woman who was always dressed in jeans and some sort of light blue sweater that matched the colour of her eyes. Her head of thin hair framed a weathered face marked by deep lines.

She presented to my office with complaints of a lump in her mouth, and despite its small and benign appearance I was concerned and referred her. The diagnosis was not one of the better ones. She had cancer and it had already metastasized to multiple sites. She attended one specialist consultation after another in anticipation of some sort of temporary cure. She visited natural doctors in hopes that they could heal her in some way that might buy her more time.

There was nothing they could offer her. Nothing. It was widespread, aggressive, and rapidly advancing. The only solace, I thought, was that she had no pain. But I was wrong. Her silence, the shrug of her shoulders, and the way she made her body smaller and contracted during our encounters spoke to the kind of pain that accompanies great suffering of the soul.

I worried, wondering if in the brief months I’d known her that I’d missed something. At the time I went on an exhaustive search to determine whether I had or not. It didn’t change where she was. It was the end of her life.

Acceptance and forming trust

It is an odd time to come into someone’s life, at the end. It has also been my experience that it is a very vulnerable, privileged, and necessary time to come into people’s lives. On reflection, I recognized my self-imposed audit as my mind’s desire to know and come to accept her diagnosis, prognosis, and the role I was to play in her remaining life. Indeed, it appeared that as she had gone through sequential specialist appointments she had done much the same—traveled the path to acceptance. I asked Violet to come talk to me weekly. It was seemingly “nothing” but all I had to give.

Those were difficult weeks. Violet would often be dismissive, arguing that somehow she shouldn’t be in my office taking up valuable time that she considered herself to be wasting. “You have better things to do,” she would say. She was so very unkind to herself. Half our encounters were spent in a kind of verbal Ping-Pong of whether or not she was justified in being there.

I realized after 2 or 3 visits that through this exchange of existential angst, trust was being formed. Regardless of how persistent, insistent, resistant, or gruff she was, I always came back with the same response. “This is my time for you. Whether you come or not, this time is your time.” She came religiously, and the resistant exchange was eventually replaced by conversations about the weather and musings about its unpredictability. It changes quite often in Halifax, providing ample opportunity for pleasant idle banter.

Through the storm of her illness I realized more trust was formed. She began to open and I learned more about my patient who was, not long ago, a stranger to me. And vice versa.

It was more difficult than I could have imagined. I did nothing but listen and the listening was painful for both of us. Violet had spent most of her life in pursuit of things that didn’t confer any sense of meaning or purpose. She had no children, no friends, and no relationships to speak of. Her companion had been a bottle. What relationships she did have with family members had been destroyed by her drinking. She had so much regret. She carried the misery triad of blame, shame, and guilt as if it were a coat worn through all the weather of her life.

Cultivating joy

I would leave our sessions wondering whether Violet had ever experienced moments of joy. I convinced myself she must have just forgotten the good moments. Perhaps between bottles they had drowned and been forgotten. I was reimagining a better life than the one she was recounting because it was altogether so sad. I wanted her to have just forgotten.

Her self-loathing was well rehearsed. I wondered how difficult it would be to have the end in sight and not be able to look back feeling you had lived in a manner that was of some value, to look back on some sort of legacy of how you would be fondly remembered. What would it be like to be in death’s embrace without the embrace of people you knew and loved who shared your journey of successes, failures, ups and downs—the undulating course of life and, ultimately, death.

The weeks went by one after another like this and it was always the same. I listened and offered gentle suggestions on how to cultivate moments of presence and pleasure. I initially suggested exploring elements of the weather like the breeze. It was an obvious place where we had connected, a place of natural awareness, interest, and observation. Later I guided her toward small gestures of self-care like a warm bath. It seemed futile. Most of the time she humoured these suggestions as if they mattered little compared with the immense task of regretting and dying.

Connecting and belonging

One day Violet came in and didn’t appear to be as dismissive. She was not trying to exit the visit as quickly as she normally did. She made no apologies for being there. There seemed to be a shift; she was lighter in some way and the lines of her face appeared to have softened. What she shared that week was such a departure from her usual that I felt ashamed for momentarily contemplating whether her cancer had metastasized to her brain. “Dr Patriquin, you’re not going to believe this,” she said with excitement. “I was at the grocery store and someone got me a cart!” I continued to listen in deep silence with wonder and disbelief.

The following week Violet came and recounted a story wherein she had been walking down the street without realizing she had dropped her keys. A little boy tapped her arm. “This little boy picked them up and gave them to me. I didn’t even know I had dropped them. And when he looked up he gave me the most beautiful smile. I felt happy. It was so wonderful.”

Silence followed but what I call pregnant silence. There aren’t really words for what we held in that expansive space while contemplating her lost and found keys. Violet had found more than her keys—something more valuable than she had had before. A sense of deep human connection belonged to her in the weeks that followed. We both felt it.

Not long after, her memory and her mind declined. I heard less of the stories and the room filled with more silence of another kind. I remembered doing the Mini-Mental State Examination, and she had paused at the item that required her to write a sentence. She peered into my eyes and uttered something barely audible but clear enough to be distinguished as gratitude. She thanked me for having understood her. She then wrote the ill-formed sentence, “And see me.”

I was deeply moved by Violet’s story. Although she had not spent a life well lived, she did end her life well. She came to know and appreciate the beauty that surrounds us always even in the face of illness and death. From the smallest gestures of kindness and connection she was able to derive appreciation, meaning, and pleasure. I marveled how seemingly insignificant the actions in her stories were. Those people will never know that such small acts meant something so very big to another human, that they enabled a dying woman to find and embrace her own sense of humanity when it mattered most. I was fortunate to bear witness to this and it allowed me to embrace my own shared sense of humanity and to live my values as a physician and as a human being. Something important had lifted in Violet to permit her to receive joy. This self-compassion was born of the kindness of others. She was healing as she was dying.

Competing interests: none declared
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