COFFEE AND CROSSWORDS | Tiffany Chen
The first things I notice are the big smile and bright blue eyes as a veteran with graying hair greets me. I notice his temples are sunken in. He looks thin and ill, but his spirits are high. Mr. L was transferred to the hospital where I met him after receiving a diagnosis of stage-four laryngeal cancer, discovered after two years of fatigue, which progressed to weight loss, then to trouble swallowing and speaking. I met Mr. L during my internal medicine sub-internship in my fourth year of medical school.
He sips on his warm cup of coffee as we talk. With a tracheostomy in place, he speaks with a muffled voice. I listen intently and learn his story. He tells me of his service in the military, his struggles with homelessness afterwards, and how he lost all connections to his family and friends. In the last couple of years, he went to rehab for alcohol-use disorder, found his own place and had been excited to get back on his feet. When I ask who his emergency contact is, his eyes light up as he tells me how he recently reconnected with his brother and sister, his only living relatives. I learn that he loves crossword puzzles and keeping his space neat. When I pre-round on him each morning, his clothes are folded nicely on a table, notebook and yellow No. 2 pencil placed in their exact positions, bed made and blanket folded.
In deciding his treatment course, his care ultimately comes down to one hard decision, something that would change the rest of his life. If he chooses surgery, his voice box would be removed, but he would be able to eat by mouth with time and therapy. If he chooses to just receive chemoradiation, he will keep his original voice but will not be able to eat by mouth due to his large aspiration risk. He would need a G-tube for the rest of his life, and his taste buds would likely be altered from the radiation anyway. He remains NPO for a few days after being labeled “high aspiration risk.” As each day passes, another day that he goes without eating, I find myself grasping onto anything to keep his spirits up.
“I’ve only had a couple meals in the last three days,” Mr. L states and looks at me with glossy eyes, pauses and continues, “I’m going to die if I keep going on this way.”
He is started on tube feeds but only gets a meal in a day since he must be NPO at midnight for his chemotherapy port placement, possible G-tube placement and possible laryngectomy in the upcoming days. I stop by the gas station on my way to the hospital to get him the daily newspaper for the crossword, seeking anything I can think of to help bring him some joy and comfort. We finally have a goals-of-care discussion with his entire team, including all the specialists that will be involved in his care, including surgery, ENT, radiation oncology and speech therapy.
As he slowly loses his voice, I find myself in a position to step in and advocate for him. I, a five-foot-tall young woman, stand in a room of prominent male attendings. They present Mr. L with his options, and I see the confusion stirring on his face. What is apparent to me is that this is an impossible decision. How do you choose between never eating again in your life and losing your voice? As the physicians talk in super technical terms, I work up the courage to say, “Do you mind if I jump in? I’ve been taking care of Mr. L this week.”
I voice how food and nutrition bring him comfort, and how he recently reconnected with his family. Maintaining these core functions is pivotal for him—a G-tube would not be a good option. In addition, due to his anatomy on imaging, he would need an open procedure instead of percutaneous. He looks at me with a thankful glance and nods, now speaking at almost a whisper and states, “Yes, I want to be able to eat and speak.”
I ask the speech therapist if they can show him the options for speaking if he were to get a laryngectomy, including how the electrolarynx and esophageal speech would work. It wouldn’t be a perfect solution, and his voice would be different, but it would mean he has some sort of voice—some agency. His eyes widen with excitement as I show him videos of patients using the devices to speak. His biggest priorities—being able to eat and share a meal with his loved ones—could be preserved, just in a modified way. I also ask the surgeons if they will talk through what life would look like without surgery—this includes a G-tube, loss of taste from radiation and preserved voice, which hopefully would improve in volume if the cancer shrinks from chemoradiation. In working with Mr. L and the team, we ultimately reach a shared decision to proceed with surgery.
I went home that day, grateful for the food I can taste, taking extra time to savor the sweet, salty, spicy and umami flavors. Even more, I am thankful for the connections that happen over coffee, brunch, Sunday family dinners and holiday meals. Over meals in my lifetime, I found out my best friend was getting married, I shared tears over heartbreak and loss, I celebrated my mom’s last day of radiation treatment for breast cancer, and I found out I was going to become an aunt to my niece. The whole spectrum of human emotions is centered in these experiences, and Mr. L serves as a daily reminder of the true definition of “food is medicine.” In taking care of him, I was faced with the raw truth of what makes us human—simple, everyday activities and fleeting moments of connection that we often take for granted.
As a medical student, I have the privilege of having more time to really learn my patients’ stories, a precious resource not as readily available to a busy resident or attending taking care of the entire patient panel. In slowly losing his voice, Mr. L showed me how to use mine to advocate for what really matters to patients, and I will continue to use my voice to support patients in my career. What is the point of a cure, a medication, or a treatment if it means we can no longer partake in the experiences—meals with family, conversations with friends, sharing a cup of coffee—that bring meaning to our lives?
On my last day on service before his surgery, I ask him if I can get him anything while his eyebrows are furrowed, working diligently at his daily crossword with his yellow No. 2 pencil. He chuckles loudly with his usual grin and bright blue eyes and jokes, “a cup of coffee would be nice.” I smile at him and say, “Soon, Mr. L, soon.”
Tiffany Chen is a fourth-year medical student at Washington University School of Medicine in St. Louis. She is pursuing family medicine residency, hoping to work with underserved patient populations and take care of patients from newborns to end-of-life. She has a special interest in pediatrics, obstetrics and end-of-life care. Outside of medicine, Chen does craft projects with friends (crocheting, knitting, watercolor), works as a florist at a flower truck and plays tennis or pickleball.