The various streetlights in Buenos Aires are considerably dimmer than they are in New York, one of the many things I learned during my family’s six-month stay in Argentina. The front windshield of the rental car, aged and covered in the city’s grime, further obscured what little light came through. When we stopped at the first red light after leaving the hospital, I broke two of my most important marital promises. I started acting like my wife’s doctor, and I lied to her.
I had just taken the PET scan, the diagnostic X-ray test, out of its manila envelope. Raising the films up even to the low light overhead was enough for me to see what was happening inside her body. But when we drove on, I said, “I can’t tell; I can’t get my orientation. We have to wait to hear from your oncologist back home.” I’m a lung doctor, not an expert in these films, I feigned. But I had seen in an instant that the cancer had spread.
PET scans are like that, radioactive tracers that travel around the body and measure how much work different cells are doing. And cancer cells are very active workers. The scans are like the ground seen from the air at night. When there is no cancer, they look like Idaho, all quiet. Really bad news looks like downtown Chicago or Phoenix.
We pulled into the garage; our tires squeaked on the floor. Ruth was silent. I was silent. I knew. She didn’t.
My wife was dead eight months later.
It didn’t take long for those films to be examined and interpreted by doctors at Memorial Sloan Kettering Cancer Center, the hospital where I’ve been a doctor for more than a decade and where Ruth had been treated when her breast cancer had first been diagnosed, three years earlier, in 2008. Only a few minutes after we parked the car, the phone in our Argentine apartment rang. It was the oncologist.
Ruth and I sat next to each other on the couch, each with a handset. The oncologist used words that were all too familiar to me — metastasis, emergency radiation, focusing on “quality of life,” not cure. Technical jargon sneaked into my questions as Ruth’s name disappeared from them. “Could she develop cord compression?” I asked. Then her voice: “What’s that?”
Ruth’s doctor never made us wait. No gentle approach, no euphemism obscuring the truth, no gingerly poke and quick retreat from the scary thing over there. He filled in many answers to unspoken questions. “There’s a lot we can do.” “This is manageable.” “You might have many years.” But then circling back. “It can’t be cured anymore. Our goal now is to try to slow down the cancer and give you as much quality of life as we can.” To paraphrase, the films meant Ruth was going to die.
I realized that I now had a secret we couldn’t discuss. I could clearly see her future … How she might suffer with me standing helplessly by her side.
Ruth appeared just as healthy in that moment as on the day I had first met her at the Baltimore Symphony, 17 years earlier. As beautiful too. But as I glanced over at my dear wife, I saw the people I have cared for over many years on the tenth floor of Memorial Sloan Kettering, where our breast cancer patients go. Ones emaciated, ones yellow from liver failure, ones full and bloated with anasarca fluid ballooning their extremities. Some Ruth’s age, many of them older. Ruth was 46.
I realized that I now had a secret we couldn’t discuss. I could clearly see her future. Where she would end up. What she might ultimately look like. How she might suffer with me standing helplessly by her side.
Her oncologist snapped me out of it as he started to talk about the back pain she had been experiencing in more detail, telling us we had to get her to New York. Soon. And, zing, I switched into doing mode. A lot had to happen, and Ruth and I set about making our lists.
Her doctor told us not to panic, because treating her cancer was not necessarily urgent. The spine was another matter. Because of where the cancer was, her spine could shift, even slightly, and that might take away her ability to walk or even to control her bowels. She needed to get home.
Four hours after Ruth landed at JFK, she was scheduled for surgery. After it was finished, our slow summer began. Ruth had pains. “Like a fist twisting my intestines,” she’d say. “Like a mule jumping on my spine.” I’d ask, “How do you know?” and she’d laugh. One month passed, she got stronger, and a scan showed that the vertebral bodies were finally free of cancer. The treatment had worked. Ruth had been propped back up after she had teetered.
The cancer wasn’t gone, but it had been eradicated from the one place it threatened her in the moment. Then her doctor started her on a hormonal pill, a common first step in many cases for women whose cancer is fueled by estrogen.
We went back to our lives. We focused on the small things. Went to the beach. She would have good days and bad days, just as long as we kept having days. When Ruth recovered from her surgery and radiation, she went back to work at her bank.
Then, in early autumn, Ruth’s doctor sat us down to tell us that the treatment was no longer working. A decision was made: Ruth would stop the hormone pill, which was mild, and get much more toxic treatment with chemotherapy instead.
When Ruth’s breast cancer was first diagnosed, friends would routinely comment to us along the lines of “It’s so good Peter knows so much about this disease.” But others disagreed, imagining I suffered more from my knowledge. Whether I was better or worse off I kept filing away as some pointless academic debate. But in the lobby of my hospital, I knew the answer: My knowledge was too clear-eyed. I couldn’t pretend for another day or hour or minute that there were good days ahead.
For the next month, Ruth set about her business, as if taking fistfuls of pills was just something that anyone does in the normal course of their lives. She continued working at her job, in large part, she explained, because she enjoyed it but also because she was sure she would die if she stopped going. She didn’t mean it metaphorically.
Then, in mid-November, she had a new complication: intense abdominal swelling. We went to see a specialist. On his screen was a CT scan of Ruth’s abdomen. I didn’t need a radiologist to help me with those images. I have looked at thousands of similar scans in my career.
In the seat next to me was the woman I loved, my effulgent bride. To her right were her photo negatives, a series of images showing the insides of a dying cancer patient. Much of the liver was no longer liver but was just cancer instead. And the swelling was due to fluid slowly collecting around her abdominal organs.
Ultimately, when the bloating got to a point that Ruth couldn’t really get around, the doctors started removing the liquid. It’s a procedure called paracentesis that I’ve performed many times. A small catheter is put through the wall of the abdomen and into the abdominal cavity where the fluid is located, and then the fluid is drained through tubing into vacuum bottles.
The first time that Ruth had the procedure, my heart leaped at what I saw. When the fluid started to flow, it was obvious it was opaque, like lymph fluid, which would have meant that the lymph channels were obstructed and she could have a shunt put in, a meter-long silicone tube that goes into the abdominal cavity, then is tunneled up under the skin, over the collarbone, and then back into the circulatory system above the heart. It’s a serious procedure with serious risks, but from that moment, I wanted that shunt and nearly insisted it be put in.
I envisioned the nutrient-, electrolyte-, and calorie-enhanced fluid that doctors had been gradually removing instead flowing back into her bloodstream and then magically reconstituting her. She’d gain back the 20 pounds she had lost in the past month. Her cheeks would fill out. Her wedding ring would stop slipping off her thinned finger.
So her doctors put in the shunt, right after Christmas, and she nearly died. Once all the fluid from her abdomen hit her bloodstream, her platelets — cells critical for clotting — started consuming themselves. Each morning, the doctors would come in bright-eyed, announcing the plan, which was always the same: see if the platelets went back to normal.
Ruth would ask all the questions while I sat very quietly in the room, listening, not out of politeness but because I knew what was happening. I knew that the doctors would head back into the hallway en masse, and out there they would really talk, the susurrus of their conversations slowly drifting back into our room. They would say exactly what I would: that treatment options were exhausted. That chemotherapy was no longer working, or, in doctor parlance, that Ruth had “failed” chemo. Her breast cancer was now as aggressive as lung or pancreatic cancer. She was terminal. After several days of the same routine, we went home, with the shunt, just in time for New Year’s.
Over the next two weeks the shunt worked in that it kept her belly trim, but Ruth got weaker anyway. My fantasies about weight gain and renewed energy never came true. Ruth’s liver had failed; the fluid, after all, had been from that. One day she stumbled on the stairs and told me it was nothing. Then she stumbled the next day and dismissed my concerns when I gasped. Then the whites of her eyes, the sclera, turned yellow. I didn’t manage it well.
We were sitting at a coffee shop when the light caught her just right, and I saw it. I tried for a few moments to just keep talking about whatever topic we had randomly landed on, but I discreetly texted a friend of mine from college, also a doctor, in medicalspeak to share the terrible news — scleral icterus.
I couldn’t hold it in anyway. “Your eyes are yellow,” I blurted out.
She was completely stunned — and panicked. “Why?” she asked. And then something totally unexpected — “What do they do about it?” I seized on this, my escape hatch from having to talk about her liver failing. I said I didn’t know; we’d have to ask. Another lie.
The yellowing, first of the whites of the eyes, later of the skin, is like the check-engine light turning on. The yellowing itself is irrelevant; it means bad things are happening inside. It meant her brain would soon become addled with toxins that at one time her liver could have cleared easily. She was near the end.
The next morning, I took the dog out. Like a cheating lover, I went just around the corner from our apartment building, took out my cell phone, and made a brief call.
“I can’t give her chemo,” her doctor said to me one day. “She’s too sick. I can’t do it. It would kill her.”
“Yes, I know,” I told him.
“OK, thank goodness, you know.”
We both paused. “One of us has to be the grown-up,” I finally said.
He agreed. “But I really don’t want to have to tell her there are no more treatments.”
“I know. Maybe we won’t have to.”
When we went to see him later that day, Ruth couldn’t get out of her wheelchair to sit on the exam table, so her doctor wheeled up next to her in his office chair. He told her he thought it was best to wait another day for chemo. You might call it a lie, but it was really a feint, leaving open a possibility that was not possible. I sat there, a silent participant in the conspiracy.
Ruth wasn’t buying it. A little slumped in her chair, propping herself up on its arms, she slowly asked those questions no one should have to ask. “How will I die?” “Will it hurt?” “Will my son remember me?”
Our house was full of friends that Saturday. Ruth spent the day on the couch, and in the evening, she told our boy that the doctors just couldn’t make her better and that she was going to die. But that he was going to be OK, and so was I. She told him where he would always be able to go to be with her and that she promised to always be with him everywhere.
On Sunday she slipped into sleep. Sunday night I held her, and I told her it was OK to go, and on Monday she died in my arms. Her last words were “I love you.”
No ghost rose from her body. No ethereal phosphorescent spirit. But it helped to realize that her departure from our lives and from humanity had no relation to what happened next, when the funeral home people arrived. The methodical sequence of gurney unfolding and white bag unzipping. It had nothing to do with her or her vitality. That didn’t fit into any bag.
The weeks passed, then the months. I don’t remember much of it.
Some days I was nearly paralyzed. Other times I felt this strange dissociative euphoria, like maybe I was playing a game with house money. I had stopped seeing patients when Ruth became sick, and as the months went by after she died, I just never put myself back on the schedule. After a while, other work filled in the gap. I think I could do it again someday, but I’m in no rush to be in those halls, looking at scans, reading over platelet counts.
Our friend Liz’s insight after she’d lost her husband: She told me she had plenty of people to do things with but nobody to do nothing with.
Our life together was really gone, and carrying on without her was exactly that, without her. I was reminded of our friend Liz’s insight after she’d lost her husband to melanoma. She told me she had plenty of people to do things with but nobody to do nothing with.
It turns out that Hollywood has grief and loss all wrong. The waves and spikes don’t arrive predictably in time or severity. It’s not an anniversary that brings the loss to mind, or someone else’s reminiscences, nor being in a nice restaurant where you once were together. It’s in the grocery aisle passing the romaine lettuce and recalling how your spouse learned to make Caesar salad, with garlic-soaked croutons, because it was the only salad you’d agree to eat. Or when you glance at a rerun in an airport departure lounge, and it’s one of the episodes that aired in the midst of a winter afternoon years earlier that you two had passed together. Or on the rise of a full moon, because your wife, from the day you met her, used to quote from The Sheltering Sky about how few you actually see in your entire life. It’s not sobbing, collapsing, moaning grief. It’s phantom-limb pain. It aches, it throbs, there’s nothing there, and yet you never want it to go away.
Originally published in New York magazine (May 6, 2014). Copyright © 2014 by New York Media Inc., nymag.com.