We have all seen patients whose distress is off the charts, or off the Distress Thermometer (NCCN). They sit in our offices, dazed and seemingly so depressed that we ask the mandatory question: “Are you thinking of hurting yourself?” Some patients just shake their head, not making eye contact, and even though they say they aren’t going to hurt themselves, we persist in our questioning because we have to and we want to make sure, as much as we can, that they are not going to harm themselves on leaving the institution.
This past week I saw a woman with an increasingly common cancer that has some more rare features. Her diagnostic path has been lengthened by reassurances from primary care providers that what she felt was “normal,” by diagnostic imaging that managed to miss a 4-cm tumor, and by specialists who reassured her that they could not feel what she had felt when she “examined” herself. And now her worst fears have been made terribly clear—she has stage IV cancer and cure or remission is a hope or prayer, if that. This cancer is going to kill her, decades before she expected her life to end.
She is in the midst of radiation treatments and concurrent chemotherapy and has had to move to the city from her rural home to have her treatments. Her family and friends are hours away but she is managing to make the most of her time away—she laughed as she told me that a great deal of her non-treatment time is spent on retail therapy. The lure of shopping malls in the city has kept her distracted in part, and the hiatus from her usual demanding work has provided her with the time to shop.
She maintained her composure as she told me about the many and repeated visits she had made to primary care providers and then specialists, each time being told that there was nothing wrong. She felt that something was very wrong in her bones or her gut or the place where our intuition lies. And finally someone felt something on physical examination and sent her for a biopsy. And now she has landed in our institution where she has seen oncologists of every stripe. It was when one of them explained what the treatment she is going to need entails, not just in the present but for the future, that she broke down. In her words, she “yelled and lost it.” The physician asked her if she was suicidal as was required and likely necessary given the extent of her distress.
“Of course I’m not suicidal! I want to live more than anything in the world!”
She told me this the day after she was in the oncologist’s office. Twenty-four hours later she was calmer, or perhaps still in shock. She had and has no intention of harming herself because what she (and all our patients) want in the face of life-threatening illness is to LIVE. They will attempt to bargain with whatever they think controls this life we live in order to have more time, not even better time, just more time to love and give and share and protect and provide for those they love. Of course I am aware that some patients do kill themselves, but to the very core of my being I believe that suicide is not a rational act—wanting to live is rational and more. It is the flame of the human spirit that lives in each and every one of us, through tyranny and disasters, plagues and inhumanity of epic proportions. Yes, at the end of life some of our patients want to end their suffering, physical or existential, or the projected suffering of their loved ones. But at the time of diagnosis, the will to live is so strong that a mandatory question seems almost out of place. Of course this patient is not suicidal. She wants to live more than anything in the world.