‘Does he know?’
The prognosis is terminal. No treatment will change that fact. His doctors know, but the patient, he seemingly does not.
In Phillip Berry’s essay, “Black Tango,” the narrator wonders if his patient knows his cancer will soon kill him (Please go read it, it’s beautiful, before I spoil it). He worries the patient is living “on fumes” of hope and resents the doctors who previously, falsely, pronounced him cured. He dreads telling him the truth. Finally, he sits down to talk with the patient and his wife. They already knew. In a sudden reversal, it is the patient who was protecting the doctor: “He saw me dancing with words, he read my evasions, and he waited. Waited until I was ready.”
I am a palliative care physician like Dr. Berry. This question ‘Does he know?’ is a common reason our colleagues consult us. We are the givers of terrible news: We sit down, we make our language plain, we do not turn away. But more and more, I think ‘Does he know?’ is often not the right question. It treats the transition from not-knowing to knowing as a single exchange of information. Yet, however skillful that conversation, it is mostly not the way my patients know.
My patient says “Me siento bien.” His eyes are light, a soft blue with gold streaks. I hadn’t noticed them when he was in the hospital for the surgery that rerouted his intestines. He hated the colostomy bag, really could not bear it, at first. Now, it’s OK. His shoulders are strong again from helping his sons load their trucks in the mornings, although he himself can no longer work. He looks so much better than when we met, but the first two treatments did not slow the cancer. He will enroll in a clinical trial in the city 50 miles away. He is not sure he wants to go through with it. He can’t drive himself there because of the neuropathy from the chemotherapy, so his wife and children will need to. They want him to enroll, and so he will. There are so many layers of knowing, his own, his family’s, in that plan.
Information is just one thin dimension of knowing. Knowing happens in the body; it can recede and roar back. The light can return to someone’s eyes, but, there is the aching of a hip. Knowing happens in shifting roles within a family, in choosing words to protect others. A patient can plan to attend a graduation that lies impossibly far in the future and—still—know. I am learning to wait before anxiously asking ‘Does he know?’ Instead, I wonder how he is knowing, or where, quite literally, where in his body, is he is keeping the knowing, today?
Julie Freedman is a hospitalist and palliative care physician at a community hospital in the San Francisco Bay Area. She received her medical degree from Harvard University and trained in internal medicine at the University of California, San Francisco. She believes that we need narrative almost as we need shelter: we build stories around ourselves in the face of serious illness. Understanding, and sometimes entering, these stories is an essential part of caring for patients. On the other hand, after this last year, she is thinking it might also be lovely to become a florist. She is on Twitter @jfreedmanmd. Her Non-Fiction essay “Vigil” appears in the Spring 2021 Intima.
