An 85-year old woman is ambivalent about having cancer surgery and I ask the surgeon what her goal might be.
“Her goal?” he asks, rather nonplussed. “Isn’t everyone’s goal to live longer?”
As it turns out, no. She declines surgery because she’s afraid that even the slightest complication will result in her having to place her husband in a nursing home. The children have long left and she is his only support. If he dies, she will have the surgery. As long as he lives, she won’t. If this causes her to die before him, so be it.
I marvel at how she can reduce a complex decision to such a simple equation.
As if reading my mind, she says, “Darling, for 70 years we have had the greatest love.”
Her sentiment moves me.
Shortly afterwards, her husband is admitted to my medical unit. He has progressive dementia and has had a fall, but fortunately no fracture. The language of medicine has declared him “stable”; to her, he is anything but. For a whole month now, I have watched her as she watches him. She arrives early and leaves late, competing with the hours his doctors keep.
All day he sits propped in a chair, almost a white-haired statue, without expression, desire or demand. Does anything hurt? Yes, but there is no advance on this. We’re waiting to get you out of hospital. Silence. Is there anything we can do? More silence.
Every day she sits beside him, holding his hand. Twelve hours a day, simply hanging on to his withered hand, gazing at him, making gentle utterances, eliciting no response and seemingly expecting none. I will him to say something, anything, but he is locked inside his failing brain.
I am frustrated, amazed and deeply humbled.
One day, I quietly say to her, “You sit here every day; does he ever say anything?”
“Did he talk to you at home?”
“Not this year.”
My curiosity gets the better of me. “Then how do you cope?”
“By remembering that I have loved him for 70 years.”
Several studies suggest that marriage confers a health benefit on individuals, with men deriving greater gains than women. Much of the benefit is thought to be related to better support structures and social inclusivity rather than an innate difference between the married and unmarried. Nevertheless, after adjusting for demographics, disease stage and treatment, unmarried and widowed individuals are more likely to present with advanced disease, receive less treatment and have a shorter life expectancy than their married counterparts. Indeed, for some of the most common cancers, the survival benefit of marriage is greater than the published survival benefit of chemotherapy.
Being an oncologist is to witness all of the pathos and drama of life, but it is particularly instructive to watch and learn from how couples cope with this traumatic diagnosis. Some people always come to clinic on their own. “My husband doesn’t do cancer,” one young woman declares, before hastily adding, “but he is good with the kids.” Another spouse comes for the “milestone moments” when there is a new scan or a thorny problem. One couple arrives together but she waits outside because the sight of my room wreaks havoc on her nerves. If I have news, she wants to hear it in the waiting room.
I see the salutary effects of a marriage where a concerned spouse urges the patient to be honest in reporting symptoms, thereby warding off potential complications. I note how a willing driver, an attentive cook, and a ready listener can influence a person’s wellbeing. A harmonious marriage creates space for optimism, “something to live for”, as my 90-year-old patient muses.
Every couple must find a way of coping with the fear, uncertainty and all the other emotions that cancer brings, but to me, the most exemplary couples are those who draw strength through unity. Meeting them is equal parts the pleasure and privilege of practising medicine.
On the other hand, I have sometimes reflected that an acrimonious marriage could be a worse toxin than chemotherapy. I once looked after a man who was diagnosed with advanced cancer shortly after his marriage broke up. A protracted custody battle had ended with his diagnosis and, as he neared the end of life, he asked to spend some more time with his children. But his ex-wife was said to detest him and obstructed access to the children on the grounds that his illness made him undependable. In a very upsetting display of an adversarial marriage, I soon lost count of the futile letters and documents I signed. I told myself that all marriages were complicated and opaque, and I heard only his version of the story.
One day, when he was particularly unwell, his ex-wife got hold of me.
“I know you won’t talk but just tell me this, will he be dead soon?”
I could only stammer, “He is terminally ill,” to which she responded, “Good, it’s all I need to know,” before hanging up. Flabbergasted, I lost my balance and fell. To this day, the resulting scar vividly transports me back to the awful rancour of the time and the helplessness we all experienced.
“Are you married?” is one of those essential questions every medical student is taught to ask. For most of my early years, the question held benign interest, merely a box to be ticked. But now, as I grow older and witness the inevitable complexities of my own marriage and those of my friends, I understand the true significance of this question and the crucial role of marriage in the experience of illness.
As someone who cares for patients at one of the most difficult time of their lives, I now see how marriage can mitigate suffering or multiply it. And while I don’t need to know the nuances of every marriage, I have realised that being altogether uninterested in the subject is like treating half the patient.
• Ranjana Srivastava is an oncologist and a Guardian Australia columnist
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