Abstract
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Angela was a vivacious 41-year-old marine biologist who embraced life. She enjoyed an active life of travel and befriended many from all around the world.
When Angela moved back to Fresno, California from Louisiana midcareer, dropping out of a fully funded PhD program to care for her ailing parents (her mother with lung cancer and her father, colon cancer), Ron was there wholeheartedly to support her. A scientist at heart, Angela viewed the world objectively and with genuine curiosity. When originally diagnosed with metastatic lung cancer in early 2015, she questioned every lab and imaging, as well as risks and benefits of treatment. She remained trusting of her doctors and proceeded with chemo and radiation therapies. Unfortunately, treatment was curtailed six months later due to functional intolerance. Knowing that his time with Angela might be short, Ron organized an Alaskan cruise with close friends and family. Although Angela enjoyed the trip greatly, shortly thereafter her pain became intolerable and she was taken to the Hinds Hospice Home for ongoing symptom management.
Angela spent two weeks at the Hinds Home during which she was placed on subcutaneous opioid drip for pain relief. Despite frequent adjustments, in addition to trigger point injections, very little seemed to help manage her pain consistently. Her more energetic days were spent with close friends and engaging in stimulating conversations with our hospice staff. Angela also reached out to trusted friends from out of town to provide emotional support to Ron. Other days were overcome by intractable pain and restlessness to which the addition of anxiolytics had minimal effects. As her terminal agitation worsened during the latter part of the second week, our nurses and providers escalated the medications, but with minimal success. During this time Angela declined chaplain support, as she did not belong to a particular faith and noted that she was unafraid of death and dying. To Angela, the scientist, it was just a natural cycle of life.
A significant turn of events happened the night before Angela's passing. That night, a Hmong family with a loved one in the adjacent bed invited Buddhist monks to pray. One by one the monks stood in their elegant yellow robes, prayer beads in hand, encircling the patient's bed with warmth and solemnity. Although the service was meant for her neighbor, amidst the oms and rhythmic chants of the monks, the crescendos and decrescendos in a foreign language, Angela's chest rose and fell and slowly her labored breaths and restlessness quieted down. She didn't require any pain medications during that time. The rest of the night Ron and Angela slept together peacefully until her passing in the early morning hours.
Angela's memorial was eventually held next to a tree on a nearby lake that commemorated her mother, who had passed away two years earlier. Friends and family gathered as gentle breezes and the warm morning sun gave life to words spoken in honor of a selfless, carefree, and compassionate human being. When Ron opened a jar of beautiful orange butterflies in celebration of Angela's free spirit, it was as if the sky was embraced by her heart of gold.
A few weeks after Angela's passing, Ron noticed a small wooden jewelry box on the couple's dresser. Inside were sparkling copper earrings, one of a starfish and the other of a Buddha (Fig. 1). Angela had apparently ordered them just a few weeks earlier from Amazon. As Ron picked up the earrings, he thought back to that night, how miraculous those chants were that brought her calm and comfort during her final hours, how seemingly pain free.
The earrings (actual photo). Courtesy of Ron Alexan.
As a hospice and palliative care fellow, I struggled with the fact that we had such a difficult time managing Angela's symptoms despite following all the appropriate algorithms in the literature. What could we have done differently? I yearned to piece together different pieces of the story to make meaning out of what happened. Could it be that the starfish represented Angela, the scientist, and the Buddha, the spiritual Angela that we never got to explore?
A few months after Angela's death, I reached out to Ron to determine the meaning of the earrings he had uncovered. A still-grieving Ron confided that in the months prior to her admission to the hospice home, Angela had not only lost her father to cancer but also her beloved friend of 21 years to complications of AIDS. Dovetailed with these overwhelming losses and physical pain from rapidly progressing cancer, Angela also endured conflicts with her younger brother, who wanted full control of the inheritance. Through this emotional turmoil, Angela took solace in collecting sentimental jewelry that she had purchased online, while she made eclectic earrings and necklaces for her friends. Although not religious, she found comfort in yoga and meditation, and explored the teachings of Buddhism.
Perhaps the earrings suggest an Angela who was struggling to reconcile recent losses and her own mortality. Perhaps the earrings suggest an Angela who was questioning God and his intentions. Perhaps the earrings suggest an Angela who was spiritually at peace and wanted her family to know that.
Whatever the answer may be, Angela seemed to have responded greatly to prayers during her final hours. Perhaps the earrings were her reminder to us that the mind and spirit should never be overlooked.