Thanking Sylvester for His Unconditional Smile

–Arne Vainio

Sometimes teaching comes when you aren’t looking for it or even have the

time to think about it. Recently, one of my partners at Min-No-Aya-Win Human

Services Clinic on the Fond du Lac Ojibwe Reservation in Cloquet, Minnesota,

was off, and I saw one of her patients. Behind and rushed (as usual), I went over

Sylvester’s records enough to know he had metastatic cancer, but his records

were sketchy and I didn’t know much beyond that. Before I went in, one of the

nurses commented that she thought he was in denial about his prognosis. That’s

the expectation I had as I walked into Sylvester’s room and introduced myself. I

expected to see a man desperately holding out for a cure and a miracle. Instead,

I met a smiling man who welcomed me into the room. His eyes were bright and

clear, his smile sincere and real. In spite of that, he was pale, gaunt, and clearly

sick. He had dark circles under his eyes and his words came in short, labored

sentences. His belly was huge, even under his baggy shirt. He was short of breath

just sitting on the exam table.


“I would like to know if my cancer is worse. Last year I was told I had five

months to live. This year I’m going to plant tomatoes.” He had no illusions about

his cancer and his prognosis; he knew this was a bad cancer and was spreading.

In the room, I went through his records again and found a CT scan report

from six months earlier from a different medical system. The report stated “interval

worsening” since his last study, with spread of cancer to multiple areas

of his liver, into his abdominal wall muscles, and into the mesenteric area. His

cancer was a GIST (gastrointestinal stromal tumor), which is a rare cancer. It

can either be slow growing or aggressive. Unfortunately, his was very bad and

spreading rapidly. The fact that he had already asked not to be resuscitated was

in his records. There wasn’t much to do at this point except to make sure he was

comfortable and didn’t suffer.


He lifted his shirt and I could see the massive tumor under the

skin on the entire right side of his belly. It was tented up at an unnatural angle

and as hard as wood. As I felt around the edges of the tumor, I could feel that

it went deep inside his abdomen and I could feel other smaller tumors.

Sometimes diseases that involve the liver cause ascites, fluid collecting inside

the abdominal cavity. I could not identify this on exam but was hoping for it,

as draining it could help his breathing. A chest X-ray showed part of one of his

ribs eaten away and a mass inside his chest. He accepted this without complaint.

Through all of this, he was smiling and planning his garden.

Dr. Vainio reflects on the lessons that come from our patients. Clinics are busy and we often see patients on a tight schedule. It is easy to be moving so fast that we don’t take the time to get to know patients and learn about their lives and hopes. What lessons did Sylvester have to teach Dr. Vainio? What can we do to help patients end their lives as peacefully and painlessly as possible? Why was Sylvester focusing on his garden and tomatoes?




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