QUEEN OF SWORDS | Jafar Al-Mondhiry
It was a small storefront antechamber, just big enough for a round table and three wicker chairs, jutting out into the street with floor-to-ceiling windows and a neon sign that read PSYCHIC. It was my first weekend in the city alone, having just moved here the week prior. I was amazed by the sheer number of these shops all around the city, how so many of these strange businesses seemed to stay afloat. Maybe there was some power in those cards I couldn’t see. Ten dollars seemed like a fair price to find out.
“She symbolizes judgment, clarity, communication—she is the voice that speaks of vision,” the reader said, eyes glued to the table while her fingertips gently framed the card.
None of it made any sense to me, but I nodded solemnly, as if playing a part. This was my first introduction to Tarot readings, and even though I put no stock in astrology, horoscopes or palm readings, I was absolutely enchanted with the process: The beautiful, blown-up, textured cards, the gravity of the scenes depicted on them, the history and mystique of the Renaissance imagery. I studied the card closely. The Queen sat upright, her sword in her right hand pointed perfectly skyward, the left hand stretched out in front of her in a state of proclamation. Her face was expressionless, a picture of absolute equanimity, with clouds all around her elevating the drama. Magnificent.
“The Queen does what she must, her words are final and fierce, her sword falls with the inevitability of Fate. The inversion of this card shows some block to communication,” she said, this time looking up to me with a sense of resigned sadness.
I had passed it off as some amusement, and even though the words were vague and general, it now shifted into something more personal. I looked at her through a fog of guilt and confusion, cast out from this carnival fair ride into some suspicious new reality. My mind was racing, and the reader let it race for a few unspoken moments before sweeping the cards off the table.
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“Median overall survival is 21.2 months with a modern combination chemo-immunotherapy for non-small cell lung cancer. This is a major improvement from just a few years ago, when standard chemotherapy alone offered only around 11 months on average. Even the elderly or frail can do remarkably well with single-agent immunotherapy, living on average 17.7 months—and depending on tumor biology, potentially much longer.”
I listened with amazement, hanging on every number and word he had. As his acolyte in training, I came to learn at his side while seeing his patients together in clinic.
“Let’s go talk to him,” he set his hands on his knees and pushed himself upwards to standing, quickly getting a step in towards the hallway.
Reflexively I sprang up too, heart pounding to get a few urgent words in before he got to his clinic room door. “I… I’m curious, how do you talk about these numbers with patients? I mean the survival numbers?”
Dr. Jerosch slowed down and looked at me. In a hushed voice he said, “You have to take their lead. At the end of the day, this is their rodeo.” He let a heavy pause sit in between us before silently turning back towards the exam room door.
A man of sixty-four, Ron picked up a few extra decades of mileage on his body from a lifetime of smoking, almost two packs a day. That faint, unmistakable smell of cigarettes filled the room, and I wondered if the slight yellow tinge on his full, thick mustache wasn’t tinted with tobacco smoke. In spite of the tube we had to insert between his ribs to drain the daily malignant effusions filling his left lung, he continued to work part time on his farm out in the deserts near Bakersfield. As we spoke about treatment planning, expectations and supportive medications, his demeanor was completely calm, fearless and quietly prepared for anything; it was as if we were talking about someone or something else. I couldn’t help rolling that number over in my head, 21.2 months—one more Christmas, maybe two? But at no point did it make an appearance.
Dr. Jerosch signed some orders on the computer and told him when infusions could start, but Ron jumped to life at that moment. “Tomorrow,” he said, and with some finality. “Let’s get this started pronto.”
Dr. Jerosch nodded. “I hear you, Ron. I’ll do my best with the schedule, sometimes we have cancellations and—"
“I’m gonna beat this thing.” Ron jumped in again. “You just watch.”
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Ron kept his breath firm but fast. Sitting in the hospital bed, he was obviously uncomfortable, but the monitors made it that much clearer. His heart was racing to keep up with his deterioration, and every time it peaked above 130 beats per minute, bells and alarms from the screen would make some of his pain ours. Ron seemed embarrassed, frustrated, but ultimately helpless around this simple fact of his body’s stress, which made itself known every 2-to-3 minutes, never escaping attention for long.
This was about a year after our initial meeting in that clinic. I had since rotated away from that clinic, thrust into new clinics, new diseases, new patients, in a frenzied pace towards something like competency in the world of oncology. Such is the experience of fellowship training, so many patient encounters, and re-encounters sometimes shocking and disheartening.
From what I could glean from a review of his chart, he spent about nine months on first line therapy before new spots started showing up in his lungs on the scans. He was quickly moved to second-line treatment but now, about two months after that, he was hospitalized with multiple pulmonary emboli, continued growth of his lung lesions, and what looked to be a new spot in the brain. We needed to start him on blood thinners, but the neurosurgeons fretted about the prospect of his new brain lesion bleeding, as there was already some blood surrounding it on the scan. In the midst of this controversy, and in the overall grim context of a now multiply relapsed/refractory cancer, an oncologist needed to weigh in. Today, I just happened to hold that phone.
I hurried through the ICU scouring the room numbers until I found his and walked right up to the edge of his bed before I realized I didn’t know what to tell him. So, I just stood there watching that labored breathing, taking it all in. He closed his eyes, as if too exhausted to address this awkward pause, or maybe he was just inured to the presence of white coats staring at him, to the point that he’d lost any modesty about it. Finally, I worked up the courage to mutter some part of my purpose for standing there.
“I’ve been reviewing all of your recent medical issues, and I… I’m really worried about. . .”
“I know,” he shot back, without lifting his head or opening his eyes. The way he cut me off left me with the distinct feeling I had nothing to add here.
“Did you and Dr. Jerosch ever talk about something like this happening?” I asked.
“You mean if my lungs filled up with clots and my brain started bleeding at the same time?”
“No, well, I mean—”. I was caught off guard by his sarcasm, or maybe just the absurdity of my own question reflected back to me. I suddenly saw all the breathless excitement over Advanced Care Planning meet the reality that were innumerable ways to get sick and die, and that even hours of discussion couldn’t have adequately prepared anyone for this moment.
“Look, I know things were getting worse. The first time, when the cancer got smaller on that first cocktail, I could feel it—I felt better. But for the past few months it just hasn’t been the same. I mean, just no appetite, no energy.”
“But did you and Dr. Jersosch talk about what that meant?”
“He would say things like, ‘I’m worried about you, Ron’, and I was coming in to see him damn near every week. And every week, I’d come back not feeling better. That’s not how it’s supposed to be… but I thought goddamn it I need to give myself a shot at beating this thing.”
“Did you ever talk about stopping the treatments?”
“We talked about lotsa things… yea, he said it may not be working, that we’d probably have to stop.”
“And what about after that? What then?”
“What then? What else is there? I’m gonna die, that’s what.”
“Is that something you’ve thought about?”
He slid back and shut his eyes, heavily sighing in a moment of exhaustion or exacerbation. “Look, when I’m getting my treatments, that’s what I’m doing, I’m there, I’m taking action against this thing inside me. And that’s what I wanted to do, I’m not sittin’ around moping about being dealt some shitty cards in life. I would just wake up and take the next right step,” he said, pointing five fingers in front of him, his hand a perfect vertical blade, drawing his head forward for emphasis just for a moment before laying back down again. “Taking action meant I didn’t have to stare at a calendar wondering ‘Is this my last summer? The last Fourth of July with my kids?’ It made me feel grounded. I liked that… I needed that.”
“You didn’t want to think about it?”
“I didn’t need to, and it was a relief. Dr. Jerosch just did his thing, and I did my thing, and that’s all. No, I didn’t want to think about it until I had to.”
“And now?”
“Ah jeez,” he shuffled in bed, now visibly annoyed with my questions. “Come on doc, I get it. It’s bad. But you guys have a way of piling it on a guy and telling him over and over. You see a guy sick with cancer and that’s it, you start shuffling around talking about ‘keeping me comfortable’—I know what that means.” He opened his eyes and pitched forward in the bed to catch my gaze. “And honestly I feel sicker every time I hear that rap. It’s bad enough,” he turned his head away and closed his eyes again, “I get it, just, please… let’s talk about how to fix this.” ----
About three days later, he died. His decline escalated faster than we could plan around, but talking to his wife in that last hour of desperation, they agreed to forgo that final, violent and undoubtedly futile resuscitation attempt. Death from an advanced cancer always has this strange cadence of fast and slow—you see it coming down the pike months or even years before its time, but the final drop is often sudden and steep. Even months of grief and awareness around death don’t stop the pain of the final bloody descent. PTSD is common in caregivers to patients with advanced cancer. This was about the fifth death in my month on service.
I ran into Dr. Jerosch weeks later and we spoke about Ron. I told him about that last conversation we had. He nodded solemnly, taking a deep long sigh. I finally broke the silence myself.
“How do you get people to see it? Get them ready, you know, to die?” I said.
“Ron knew it. I knew it. You knew it too, as soon as you stepped into his hospital room. But did you see the flowers in his room? Did you talk to his wife? Did you notice the Bible out on the table?” He stopped again, turning his head towards a window in a wistful look of remembrance.
“When his disease progressed and we started talking about second line therapy, he was really scared. We started talking about what would happen if he got sicker. He was looking worse and I actually brought up the idea of hospice, but he didn’t want to hear it. So, instead, we talked about his wife Lisa, what life in the house is like now that he’s slowing down. But he shook it off and just asked me when we could start.”
Dr. Jerosch sighed again and looked down at his shoes. “He had a lot more he wanted to do. Bills piling up, supporting his wife, showing up and doing service each week at church, seeing his grandkids every weekend. Even when he was sick, he stayed busy. Each week we took a little bite out of it, talking about what they knew or saw in his illness, how he was adjusting things… sometimes I’d push him and ask what they’re going to do when he’s gone. He would tear up a bit and tell me a story or two, what he accomplished as a younger man turning the farm into something profitable and sustainable, how proud he was of his kids – an engineer and a veterinarian – and about small things in his grandkids that reminded him of himself.”
“When I first met him, I had a lot of hope he would be one of our ‘long-responders’ we sometimes see with immunotherapy, but as the weeks dragged on it was clear he was heading for a cliff, but what do you say when a man is trying his damnedest to turn the car around? Kick him out of the driver’s seat?”
This time he stopped and looked directly at me. “Sometimes there’s more to talk about than the days left on the calendar.”
I thought back to that Tarot reading, to the piercing vision of the Queen, to the clarity of her regal decrees, but her presentation in reverse. I thought about what it would’ve meant to Ron to hang some number above his head after that first meeting, or the second, and to declare his Fate. Maybe some things needed to be said without the sword. Maybe some solace sits within those moments together before death, and beyond its apparition, away from its constant countenance in the cancer experience.
Jafar Al-Mondhiry, MD, MA, is a medical oncologist working at Inova Schar Cancer Institute in Fairfax, VA, specializing in the treatment of cutaneous malignancies. Originally pursuing graduate training in Continental Philosophy and Medical Ethics at Pennsylvania State University, he has maintained a thriving interest in the medical humanities throughout his training and early career. He completed medical school and internal medicine residency training at NYU Grossman School of Medicine and hematology/oncology fellowship training at UCLA Ronald Reagan Medical Center. He holds an assistant professorship appointment for medical education from the University of Virginia. Particularly areas of interest include issues in medical education, medical history, communication skills training, and palliative/supportive care for patients with advanced cancers.