‘I knew when to adjust her morphine and even how many laxatives she needed. I knew her in better times and as she worsened. There are endless notes about all of this but nothing of their relationship’ These are the final months of a 10-year battle with cancer, and even to someone who resists the description, a battle is what it has been. First, the surprising diagnosis and the long time it took to nail it, then the reprieve that lasted longer than anyone expected but never without the knowledge that one day there would be progression, and finally the progression at which multiple lines of chemotherapy have thumbed their nose. At 60, her body looks fit but her expression is worn. In the three years I have known her, this is the worst she looks. “What do you do these days?” I casually ask. “You know, stuff,” she casually answers. “And how are you feeling?” “All right, I suppose.” I feel stuck, wishing she would allow me in. “No, you are not all right,” a voice interrupts gently but firmly. “Tell me more.” “She coped much better in the past, doctor. This time is different, she’s weak and tired.” My patient closes her eyes. “You decide about chemo.” “No, that will always be your decision but I will help you.” Again, that reassuring voice and calm hand that creates a lump in my throat. What heroic attribute does it take to do this every day? What is the cost of ensuring that a vulnerable patient has a voice even when the decision is quicker for someone else to make? I spare her the trauma of an immediate decision and say to call me when she’s ready. I tell her honestly that I wish she felt better, ensure palliative care visits, renew drugs and finally they are ready to leave. “She is lucky to have a daughter like you,” I say. They nod silently, tearfully and I am left to write my notes. Her condition declines and it becomes apparent that further chemotherapy is futile. Then, I receive a call that my patient’s subtle imbalance has worsened, prompting me to rush her to emergency where the brain metastases I feared are confirmed. It is not long before she dies, and with a heavy heart I call to offer my condolences. “You were simply amazing,” I say. “I miss her so much.” “Would you eventually consider grief counselling?” I suggest, her emptiness worrying me. “I think so.” “Doctor, did you receive my card?” “Not yet but thank you.” Months later, a tattered envelope, lost in journey, arrives on my desk. Inside is a delicate card with exquisite handwriting. It comforts me to know that my patient died peacefully at home as she had wished. It mentions that although the truth got harder to bear, she appreciated my telling it and trusted me implicitly. In a lifetime of private doubts, I cling to this powerful validation. But it is the final segment that takes my breath away. Thank you for recognising our relationship, it says. That’s sweet, I think. We weren’t your usual couple but you never dismissed us, and you never made us feel awkward, it continues. And it’s only then that the realisation drops on me like a bomb that the extraordinary couple that I had heralded in those countless visits to the clinic were not mother and daughter but a devoted lesbian couple who had been together for decades. I feel simultaneously mortified, aghast and ashamed. And then puzzled. Why didn’t they challenge the stereotype of women coming to the clinic together, which happens to be elderly mothers with supportive daughters? Why didn’t they gently (or firmly) invoke their status, when I openly assumed them to be mother and daughter, which would have allowed me to apologise for my unconscious bias? How could they tolerate my description? Miffed, I find a nurse. “Did you know they were partners?” “Yes,” she shrugs. “You didn’t?” Her response doubles my dismay. No, I didn’t. I knew everything about her cancer, the trend of her haemoglobin and the times she spent in hospital. I knew when to adjust her morphine and even how many laxatives she needed. I knew her in better times and as she worsened. There are endless notes about all of this but nothing of their relationship. Their grief was staring at me but I didn’t see it as the particular grief that afflicts lovers and partners. And it wasn’t because I didn’t care; it was because I didn’t think. It never crossed my mind that two women in my clinic, decades apart in age, could be anything other than mother and daughter. And now, in the wake of a letter that praises my “generosity”, my failure feels as monumental as it should and the redemption as undeserved as it is. My surface emotions eventually settle, only to be replaced by a deeper discomfort. If they trusted me with her life, then why not their relationship? What did they think would happen if they told me? One explanation is that they didn’t care as long as I continued to deliver good healthcare. But this is naïve because identity lies at our core. Our closest relationships define us, which is why my patients never fail to tell me that they have 11 grandchildren and one on the way, that they have been married for 55 years, or that they would like a week off from chemotherapy to marry their best friend. I concede with a heavy heart that they made a choice between correcting their doctor and receiving good care. Tired of past experiences hinted at in the letter, they elected not to trade revelation for potential judgement and discrimination, especially at a vulnerable period in their life. After all, they were acutely aware of the impact of gender and sexuality on health discrimination and that less than 50 years ago, homosexuality was deemed a mental illness. They had found a doctor they trusted and they didn’t want to risk upsetting the dynamic. I knew in my own heart that this wasn’t true but how would they? In tolerating my error and then thanking me for being their doctor, I know how lightly they let me off. But I will never forget the disservice I did them by failing to acknowledge their love, which to my mind was as genuine and poignant as any other I have seen. It was a relationship that withstood not just the ravages of cancer but also the assumptions of society. In atonement, I can only say that when considering the relationships of my patients, I ask more and assume less. But I also hope that patients will not be afraid to hold the healthcare profession to a higher standard. Doctors must improve at asking questions about sexuality, and patients should feel comfortable answering them. This is not just nice etiquette but good medicine. In the quest to achieve healthcare equality, it’s important we remember this facet we rarely discuss. Source
