Current Events

Day before yesterday, thanks to the initiative and editorial prowess of Professor Andrew Lo, I had accepted for publication, in the highly regarded Journal of Investment Management, a modest compilation that I had written originally in 2008 for my colleagues at Harris & Harris Group, "Some Lessons Learned in 42 Years of Business." 

Yesterday morning, our daughter, Elizabeth, arrived on a redeye from the West Coast for a visit through tomorrow.

Yesterday afternoon, two months ahead of deadline, thanks to the Herculean efforts of my colleagues, we submitted  to Cold Spring Harbor Press the manuscript of my book, Incurable: A Life After Diagnosis.

Today, I will go to MSK to have blood drawn.

Friday morning, I will be readmitted to MSK for a procedure in which interventional radiologists are to insert a permanent drain in my body to attempt to reduce the fluid level in my peritoneal cavity caused by ascites.

Saturday morning, if all goes well, I will return home.

Happy Fourth of July Weekend!

Taking Inventory

With the aid of a drug, Reglan, I can still eat small portions of chicken, potatoes, rice, pasta, eggs, cream o'wheat cereal, yogurt, molasses cookies, apple sauce and cooked zucchini. I can drink water, Gator-Ade and cranberry juice. I can sleep, in spite of a worsening skin rash, in the fetal position on my left side for an half hour at a time, occasionally even an hour, before I am awakened by musculoskeletal pain from lying in one position or by the need for a bowel movement. I can see well enough by peering to hunt-and-peck out this post, to read in good lighting and to watch television. I can concentrate well enough to read a newspaper article, though not a book. I can still work on the book with our editorial and design team for brief, intense stretches. I can still remember things, though sometimes I have real lapses in short term memory-- I am hoping such lapses are owing to the Reglan. I enjoy listening to music, mainly classical and jazz. I am strong enough to walk a few blocks, but I would have physical difficulty enduring another long wait in the Urgent Care Center. I can wear a loose polo shirt, though not a tee shirt or a dress shirt. In certain positions, if I am not too tired, I can sit pain-free in a comfortable chair for a couple of hours. Sometimes I have no fever, often I have only a mild fever and only rarely do I have chills and shakes. I am taking Tylenol now, but only when my temperature starts rising. I like getting emails from family and friends, and I check my CrackBerry often.

We interviewed home hospice services late last week and expect to sign a contract with one early this coming week.

Returning to the Winner's Circle

In today's sixth race at Belmont Park, Hot Money circled the eight-horse field on the turn for home in a seven furlong turf race and won going away by a half a length under jockey Rajiv Maragh. Unlike today, Hot Money had not gotten smooth trips in his first two races. But those two losses did not deter the bettors from backing him down to second choice at 2.4-1 odds today. Hot Money's cumulative gross earnings are now some $87,000. Although I was not well enough to go out to Belmont Park, Susan represented us well in the winner's circle.

Because Hot Money works extremely well on dirt in the mornings, we are going to race him next on dirt and see if he is as good or better than he is on turf. Meanwhile, there are races in coming days for Mustang Island and for Backslider, which would be making his debut.

The Little Children

The most heartrending sight at a cancer center is the kids with cancer. If they and their families are not amongst the most suffering and bravest of humankind, who could be?  If I believed in a personal God, I think that my compassion for them would be combined with extreme anger.

Illness and Inefficiency

During my adult life, I enjoyed exceptionally good health. Consequently, I find that being ill, especially in the context of terminal decline, to be frustratingly inefficient. I have spent the last 12 hours or so, starting about 5 PM yesterday, dealing with a low-grade fever, bodily pain, diarrhea and slight nausea. I have been able to eat only small portions of food and sleep only in stretches of about an half an hour. No interactions with people outside my immediate household, no writing, no reading, only small snatches of television.

An existence consisting primarily of tending to my miseries while in inexorable decline is not only boring, but also strikes me as self-indulgent and ignominious. I am very fortunate that, so far, I have still been able to work most days with my colleagues-- via email, Skype and FedEx-- in recasting this blog into a book. Otherwise, I would have no project and little work to show for my waning days.

Purgatory

After studying my blood tests and examining my right Achilles tendon, the physician on duty, Dr. Klotz, thought that the soreness and stiffness in the area of my Achilles tendon was either a blood clot (I'm not kidding) or a swollen tendon caused, most likely, by Levaquin. Rather than, as he said, torture me with more tests or readmission to the hospital, he sent me home about midnight with two new antibiotics. I was most grateful for Dr. Klotz's common sense and compassion.

Heaven, hell, and purgatory can be located anywhere. The emergency room of a cancer center is one outpost of purgatory.

A Weird Drug Side Effect

I'm headed back to the UCC. But first we'll have dinner at home. There is no telling how many hours I will have to wait in the UCC to be seen.

The antibiotic, Levaquin, that I began taking on Saturday, may have swollen or ruptured my right Achilles tendon.

A Black Comedy, In Three Acts

At 7:30 Saturday morning, Susan and I reported to the Urgent Care Center, as instructed on the computerized appointment schedule that MSKCC maintains for each of its patients. Dr. Glare had tried to arrange for me to bypass the UCC and be seen directly by the Interventional Radiology department, to determine whether the I.R. doctors could remove some of the ever-increasing fluid in my body cavity. Thus, I was feeling a bit grumpy about having to keep a third appointment with the UCC, as the first two such appointments had proved to be an exhausting waste of time. 

We waited about two hours for a confused UCC physician to see me, who said that my records showed that I had gone to I.R. two days previously to have fluid drawn. Nevertheless, she agreed to examine me ultrasonically to see if there were fluid she could access with a needle; she found an accessible pocket and drained some three liters of fluid. I would guess that there are another ten liters where that came from. After I was dismissed, and we went home and had lunch, I discovered that the UCC had forgotten to disconnect my Mediport. In a lamentable mood, I paid my second-- this time gratuitous-- trip of the day to the UCC.

When I returned home, I worked on this book via Skype with the book designer and editor and suddenly developed chills so severe in the 90- degree summer temperature that I had to don a heavy cashmere jacket, ski parka, stocking cap, and Arctic gloves to stop shaking. My temperature shot up to 101.9 degrees. Partly because of dread of another long, uncomfortable wait, I delayed going back to the UCC. Also, I was trying to think through whether dying of an infection might not be as good an alternative as I am likely to get. 

I concluded that I don't know anything about dying of an infection and reluctantly went back to the UCC about 7 PM. About three hours later a doctor saw me, who recommended that I be hospitalized and begin intravenous antibiotics. In spite of my having had an adverse reaction to a penicillin drug in the past, she recommended using a penicillin-related drug. When I asked what would happen if I got an anaphylactic reaction, she said, "We will intubate you."  

After signing a form indicating that I was acting against MSKCC's advice, I got a prescription for non-penicillin antibiotics, and we went home. Altogether, my three trips to the UCC had involved about eight hours of waiting around, with pain mounting as fatigue deepened. As I finish this post on Father's Day morning, I have gotten a little rest, and I have only a mild fever.

A World of Madness

Because I have expressed my willingness to trade quantity of life for quality of life, MSKCC's palliative care unit's protocol for me yesterday included having me see a staff psychiatrist to make sure that I am not depressed. The psychiatrist seemed to agree with the palliative- care professionals, and with my own assessment, that I show no signs of depression. As I have tried to reassure all concerned, my thinking about quality of life versus quantity of life and my personal disinterest in staving off death to a bedridden, drug-addled bitter end were formed long before I was diagnosed as an incurable.

Yesterday, I also continued an extended conversation with the professionals in the palliative-care unit not only about what they might be able to do to alleviate some of my symptoms, but also about the limitations on their care in general. (Given the boundaries of laws and medical ethics, I doubt that their limitations are any different from those of professionals in other secular cancer centers.) My understanding is that much of what they can do is to try to 

alleviate patients' pain with opiates. The opiates in turn cause constipation, which can cause an anal fissure, as indeed happened to me in the aftermath of all of the complications from my second surgery. If I had to choose between being dying sooner and getting another anal fissure, dying sooner would be an easy choice. As the doctors tried to do after my surgeries, the palliative- care doctors and nurses try to offset the opiates with other drugs to avoid constipation, while trying not to trigger in turn diarrhea. Palliative care can also include palliative sedation in the final stage of dying, but not before.

I told the professionals in the palliative-care unit that, to me, taking palliative drugs that would require taking other drugs to treat the side effects of the palliative drugs, and so on, was a form of madness. The nurse-practitioner nodded and said that was the world in which they worked, a world of madness. I replied that I very much wanted to avoid entering that world. As I told them-- and they tacitly seemed to agree-- I think that the only alternative for someone in my situation who does not wish either to enter that world of madness or, out of respect for the sensibilities of family, to commit suicide, is simply to stop taking food and water once further prolonging of the dying process seems unwise or intolerable.

In the meantime, I agreed to go back for a third time to the Urgent Care Center to see if the doctors there or in Interventional Radiology can find some way to put a needle in my body and drain from it some of the steadily mounting fluid. And I agreed to try some non-opioids, that supposedly do not cause severe side effects,  to try to alleviate some of my symptoms. Fortunately, I read the package insert before I actually took one of the pills: one of the possible side effects of this non-opioid painkiller is constipation so severe that it requires manual extraction of the feces.

The Chemotherapy Industry

According to today's "New York Times:" The academic journal "Health Affairs" reported that, after Congress cut back payments for certain cancer drugs, lung-cancer specialists in the aggregate who administer chemotherapy in their offices responded by treating more patients with chemotherapy and by switching to more expensive, but not necessarily more efficacious, drugs, thus recouping lost income.

Back to Bed

The stasis has resolved itself. Today, I will consult with MSKCC and think about whether I can chance taking more painkillers. In the meantime, it is raining hard, and I am going back to bed.

What to Do Now?

Today, I took two 5 mg doses of Oxycontin, for a total of 10 mg or one quarter of the maximum 40 mg daily dose that MSKCC prescribed for me. The drug arrested my pain, but it also has paralyzed what is left of my colon. Having gotten only about three hours of sleep last night plus a nap of about an hour's duration today, I am exhausted. When I go to sleep, I reawaken almost immediately from an urge to have a bowel movement, which my inert colon is incapable of delivering. In the absence of better ideas, I will keep drinking a lot of water, not eat, and try to stay awake. I have a previously scheduled appointment tomorrow (Thursday) afternoon with Dr. Glare at MSKCC. 

However well intended, feeding drugs to terminal cancer patients, especially drugs to counteract the side effects of other drugs, strikes me as ofttimes mad. Predicting the side effects of any drugs in people as compromised as incurables who have previously been subjected to various draconian treatments seems to me to be guesswork, however educated.

Drugs For the Dying

Because I have wanted to avoid side effects-- the most common of which is constipation, which can have serious consequences for someone who has had part of his colon removed-- and I have wanted to avoid addling my brain, I have been fighting the temptation to take painkillers. On June 1, I relented enough to take a Tylenol; and since then, I have taken about four more. Last night, a Tylenol wasn't sufficient to mitigate the pain radiating through my body cavity, and I could not sleep at all. With great misgivings, I started down the one-way street of drugs for the dying. 

I took the minimum dose, 5 mg, of Oxycodone HCL that MSKCC had prescribed for me. The pain eased quickly, and an hour or so later, I began sleeping for about an half hour to an hour at a time, for probably about three hours of sleep altogether. Oxycodone mimics morphine. My current prescription permits me to take up to 40 mg per day. 

Witness to Greatness

Yesterday morning, Susan and I rode with friends in their Maybach to New Haven to see the Stubbs paintings. The backseat of that splendid automobile is so comfortable, and the company in the car was so delightful, that the drive to and from New York was pain-free for me. Of the Stubbs works, the piece de resistance in the New Haven museum is the monumental canvas of the first of Stubbs' known portrayals of  lion/horse encounters.

When we returned from New Haven, it started to rain. My son and I watched on TIVO the second start by the phenomenal rookie pitcher, Stephen Strasburg. After dinner, on a live television broadcast from Los Angeles, we watched Zenyatta set a new record for thoroughbred horses, in a hard-fought victory, by winning her 17th straight start.

By the time I went to bed, I had a fever and was in some physical distress. But I had been a beneficiary of greatheartedness and witness to greatness throughout the day.

Fighting for Quality of Life

Although I have always felt profound respect for any individual's urge to postpone his or her death for as long as possible, I have for many years been appalled at the enervating and degrading treatments inflicted on incurable cancer patients. When I was given a chance at a cure, as noted previously, I was cavalier to the point of foolhardiness about the possible risks and probable consequences of undergoing two major abdominal surgeries, each of which included a liver resectioning. I have paid and am paying a terrible price for those unsuccessful surgeries. Nevertheless, even in the midst of my worst post-surgical complications and ordeals, I have never regretted having risked everything for a chance of cure. Conversely, in cases where cure is not possible, it has been been clear to me for many years that, if I were in that dire situation and were given a choice, I would opt for quality of life over quantity of life. 

The biggest surprise to me when I commenced cancer treatment is that little goes according to plan, and nothing is black or white. Even with a garden-variety cancer such as my metastatic colon cancer, a high percentage of my symptoms from the cancer and from the treatments were inexplicable to even the renowned specialists taking care of me. Consequently, their ability to predict the consequences of undertaking a given treatment seemed to me to be very limited-- not by their undoubted expertise, but by the primitive state of the art. 

While no treatment option was ever presented to me as a choice between quality of life and quantity of life, I did read implicit understanding of my priorities into my medical oncologist's approval of my decision to postpone further chemotherapy, in the form of FOLFOX, for as long as possible after the unsuccessful surgeries. Even if FOLFOX had proven to be efficacious for me, as it did not, it was never presented to me, and it is by no means clear, that commencing FOLFOX earlier would theoretically have prolonged my life longer than commencing FOLFOX later.

I am in awe of the doctors, nurses, and aides who take care of cancer patients. Certainly, I cannot imagine that I would be able to go to work each day and watch my patients and their families suffer, knowing-- whether they are in denial or not-- that so many of them will die before their time, often in the wake of horrible agonies. From what I have read and observed, the ability to compartmentalize, the ability to focus on fighting death, and the belief in helping to advance the state of the art are critical to oncology professionals maintaining their morale. Such a milieu is not conducive to advising a patient that a treatment option might enhance quantity of life but would almost certainly decrease quality of life. Thus, in my limited experience, a cancer patient trying to weigh a strategic desire for quality of life against an actual treatment option is left to his or her own devices.

Now that I am officially in palliative care, it is clear to me that the ethos in either hospice care or plain palliative care is for the patient to ingest various drugs to deal with pain, blockages, and other symptoms. In a typical scenario, when the patient becomes sufficiently helpless, the patient is moved around in a hospital bed--  temporarily installed in his or her home-- to avoid bedsores. Eventually, he or she may well be in diapers and in a coma or otherwise has no more desire for food and water. If do-not-resuscitate orders are in place and are actually observed, the patient is finally allowed to die, in a process that can legally include the withholding of all sustenance including liquids and the administration of pain killers that may have as a side effect, but not objective, the hastening of death. 

In summary, the oncology industry, for understandable reasons, is geared towards promoting quantity of life, even at the inadvertent price of compromising quality of life. 

I made good use of my respites from treatments. During the first break, in June and July of 2009, Susan and I socialized and even went to Saratoga Springs for six days. During the second break, after I recovered sufficiently from my second surgery in early August, we resumed travel: Paris; multiple trips to Florida and seeing relatives and friends at points on the East Coast between Boston and Southern Florida. During my penultimate trip to Florida, I was able to be with my father during the last hours of his life; and Susan and I went to Australasia for a month. 

Even now, I have shards of quality of life that I would not have if I were in the throes of irinotecan/Erbitux. This morning, friends are driving Susan and me to New Haven to view the world's largest Stubbs collection, bequeathed to Yale by Paul Mellon. 

Would I live longer had I submitted to irinotecan/Erbitux? Probably, if that chemotherapy had proved to be efficacious for me. In any case, delaying death might be a mixed blessing, given all that is wrong with me now and with my belly getting bigger and more uncomfortable every day. Because of cancer's endless supply of tricks, one must be careful about making wishes. 

My growing belly vexes me constantly.  Up until early 2009, I ate robustly and got some three hours of exercise a day, including an hour of walking. I weighed about 165 pounds. Today, I can eat very little, and I get very little exercise. Consequently, except in the belly, I am the thinnest that I have ever been in my life. I weigh 180 pounds.

If I could be granted another 30 years of life in my current condition, would I wish for it? No, I would not. It follows that I have no interest in trying to withstand six months of a hideous chemotherapy, like irinotecan/Erbitux, in hopes of postponing the relief of death for several months.

Enervation and Desires

As a result, I think, of clouding cataracts, my vision is dimming. Each day, my belly swells, and my stamina ebbs. Three weeks ago, I rarely took a nap. Today, for the first time, I needed two. Looking ahead, I am struck by Tolstoy's words on the death of Nikolai Levin in Anna Karenina.

"His sufferings, growing more and more severe, did their work and prepared him for death . . . Hitherto each individual desire aroused by suffering or privation, such as hunger, fatigue, thirst, had brought enjoyment when gratified. But now privation and suffering were not followed by relief, and the effort to obtain relief only occasioned fresh suffering. And so all desires were merged in one-- the desire to be rid of all this pain and from its source, the body."

Whistlejacket in My Eye

When we commenced the project of reshaping the material in this blog as the heart of a book, one of the first subjects that Nanette Stevenson, the book's designer, raised-- via conference call on Skype (Nanette lives and works in Alaska)-- was artwork for the dust jacket and possibly within the book itself. When she asked if I had any suggestions, I had not yet thought about a dust jacket. As we began to discuss suitable art, my eye fell on a pile of books on my coffee table, and I began fumbling through one, Tamsin Pickeral's The Horse: 30,000 Years of the Horse in Art (Merrell Publishers Limited, London 2006). After flipping through two or three pages, I seized upon a reproduction on page 218 of a 1770 painting by George Stubbs, A Horse Frightened by a Lion.

This Horse Frightened by a Lion is part of the permanent collection of the Walker Art Gallery in Liverpool, where Stubbs grew up. Altogether, Stubbs is known to have produced 17 paintings, including one enamel of which I am aware, on a Romantic horse- versus- lion theme. I saw this particular painting about three-and-a-half years ago at the Frick Museum in New York, when it was one of 17 Stubbs paintings on various subjects on loan in a traveling exhibition in the U.K. and the U.S.

Evidently, Stubbs deliberately portrayed the lions in this series as mangy "demonic mockeries" (page 117, Stubbs & the Horse, Yale University Press 2004). "In Stubbs' world, the horse is first and noblest among animals and the lion at the other end of the scale.... In his later treatments of the theme, Stubbs made the horse white and the lion more shadowy, heightening the sense of good against evil (Ibid.)." To paraphrase the Frick curator's notes, what mattered was not that the lion would inevitably devour the horse, but rather that the horse struggled nobly.

From the time that I was first exposed to Stubbs, he has been my favorite painter of equine scenes. He was one of the first artists to paint famous thoroughbred race horses; and, as a result of gruesome anatomical studies, his understanding of equine anatomy was unmatched by artists in his day. About 1984, I purchased my first art book that featured prominently Stubbs' works, The Horse in Art by John Baskett (George Weidenfeld and Nicholson Ltd., 1980). My small library contains also a copy of Stubbs' 1766 The Anatomy of the Horse (Dover Publications, Inc. 1970).

Regretably, I have never visited the museum that Paul Mellon established in New Haven, the Yale Center for British Art, which houses most of the 40 Stubbs works that Mr. Mellon, a leading owner and breeder of thoroughbreds, collected during his lifetime. Nor have I ever actually seen my favorite Stubbs painting, the startlingly modern, life-sized, and almost photo-realistic Whistlejacket, acquired in 1997 by the National Gallery, London. But I do have Whistlejacket forever in my mind's eye.  

A Primer on Racing

Several friends have emailed to ask if we made it to the races yesterday and to inquire about Mustang Island's degree of success in his race. We did get to Belmont Park in time to see the last four races on the card, including the $400,000 Grade I Manhattan Handicap, the $1,000,000 Grade I Belmont Stakes, and, two races later, Mustang Island's $48,000 allowance race. After the track announcer declared that yesterday's feature race was the 102nd running of the Belmont Stakes, I couldn't resist saying to a friend, "I missed the first 55."

In handicap races, the more accomplished horses in the race carry more weight. Allowance races are good quality races, and non-graded, listed stakes are even better. Grade III and grade II stakes races are progressively higher quality races. Grade I stakes races are even higher quality races, and a handful of so-called classic grade I races like the Belmont Stakes are the defining races for a generation of horses. Most owners, trainers, and jockeys never win a grade I race in their careers. Although a horse of mine, Primitive Pleasure, placed (i.e., finished in the top three) in two grade I races, and another horse of mine, The Wedding Guest, was favored in a group I race, I have never won one.

Yesterday, there were many top horses competing in important races at Belmont Park. The outcome of the Grade I Manhattan Handicap, in which our trainer, Christophe Clement, ran two horses for two different owners, was illustrative of the vagaries of racing. One of his trainees, champion Gio Ponti, went off as the 6-5 favorite in the field of 11 and finished second to his other entrant, Winchester, a 20-1 longshot. In grade I races, much more than prize money and cherished trophies and memories are at stake, including potential careers at stud and the values of the horses' dams (mothers) and siblings.

In the race in which Mustang Island-- a horse that is always anxious to run-- participated, we wanted Rajiv Maragh, his jockey, to cover him up early so that he would not burn energy fighting against Maragh's hold on the reins. When a horse is covered up, it has a horse directly in front of it and preferably one also just to its outside. As a result, the horse paces itself to keep from running into another horse. As the race unfolded, as we had anticipated, the horse in the number one post position sprinted away to a clear lead on the extremely firm track surface. Unfortunately, none of the other horses dropped down to the open spot on the rail. Thus, Mustang Island had daylight in front of him the whole way. As a result, he fought for his head throughout the race and never relaxed, finishing third, beaten less than two lengths for first and a nose for second. Having lost two races in a row employing this strategy with Mustang Island, perhaps we should permit him to go to the lead at the beginning of his next race.

As long as my horses run competitively, adverse racing luck never bothers me. I am mindful that I have won my share of races with an assist from good racing luck. 

Belmont Stakes Day

Tomorrow is Belmont Stakes day, traditionally the most important day of racing each year in New York, which has more important races than any other state. Upon reflection, I can recall having missed attending only the 1968 running of the Belmont Stakes-- the "test of champions," at a distance of a mile and a half-- in the last 47 years.  A man must have priorities. 

Because there is no Triple Crown on the line this year-- different horses won the Derby and the Preakness this year, and neither of them will contest the Belmont-- attendance will be below that of years of peak interest. Nevertheless, the undercard will be loaded with big fields of horses competing for big purses. The race prior to the Belmont Stakes will be the $400,000 Grade I Manhattan, in which the favorite to win will be Gio Ponti, trained  by Christophe Clement.

Two races after the Belmont Stakes, we will run Mustang Island, which will likely be first- or second-choice in the betting in a modest $48,000 allowance race on the turf restricted to horses bred in New York State. Still, it would be a thrill to win a race on Belmont Stakes day. 

Because the Belmont Stakes and our race are so close together in time, if I feel well enough, we are going to try to attend that span of races. If we go, we will park at Christophe Clement's barn, which will shorten my walk to the grandstand and our box. To maximize my chances of feeling well enough, I will try to take a nap after lunch tomorrow.

The Psychology of a Decision

I have decided to undergo no more chemotherapy. For days, I tried without success to envision my having peace of mind while subjecting myself to a course of chemotherapy in the form of irinotecan and Erbotux in the knowledge that at best, at my advanced stage of incurable disease, my courting of this particular chemotherapy's handmaiden, grotesque suffering, had been for the sake of short prolongation of life and the dying process.

At no time in my internal deliberations was I able to convince myself that this chemotherapy under these circumstances would be good for my family or consistent with my desire to maximize the quality of my remaining days. Thus, ironically, unlike my agonizing over the years about countless trivial choices, I was able to make without angst this life-altering decision. 

Time's Arrow

When I was given the opportunity to choose elective surgeries and chemotherapies that would give me an estimated 20 percent chance of a cure, I was almost indifferent to the pain and risks that undergoing the surgeries would entail. Because it was certain that I would not live for long if I did not have the surgeries, the potential reward was disproportionately greater than almost any risks. 

Now my cancer is growing aggressively and rapidly restricting my life. Through the combined pressure of fluid accumulating in my body cavity and swelling of my liver and spleen, my organs have pushed through my stomach wall and are now protruding beneath my skin. The doctor who saw me at MSKCC's Urgent Care Center on Sunday and this morning told me that the flexibility of the skin will however prevent my organs from bursting through my skin into the open. 

This morning at the Urgent Care Center, the doctor was once again not able to locate with ultrasound any fluid in a location where it could be removed. Because my CAT scans show that my colon is thickening, and putting solid food into my stomach has become too painful for me to bear, she also had X-rays taken of my colon to see whether it has any blockages. Although my colon is not blocked, I was given a list of symptoms of such blockages to monitor. It is also now possible that my intestines could become twisted and blocked as they protrude though hernias in the fascia of the stomach wall. If I develop blockages, the first treatment would entail hospitalizing me with a tube running down through my nose into my stomach.

Because I will probably die soon and almost certainly die within a year or so no matter what treatments I undergo, the suffering and humiliations of further chemotherapy and the risks of prolonging dying now loom large in my thinking. When I was first diagnosed by Dr. Saltz as incurable, then once again diagnosed by him as incurable after the surgeries failed, I told him that my priority was quality of remaining life, not quantity of remaining life. 

Increasingly, the quality of my life is eroding. Blood tests show that I am anemic. I can't eat normal amounts of normal foods, partly because my swelling spleen and liver are increasingly squeezing my stomach, thereby restricting its capacity. I can't exercise anymore, beyond walks of a dozen blocks or so.The taut skin of my belly is so sensitive that showers are painful, and I dread the mere touch of fabric. I am starting to be afflicted by fevers of unknown origin. Pain is spreading into new locations in my body-- today, into my right side, just below the ribcage. Last night, for the first time, I took a pain killer-- 500 mg of Tylenol-- so that I could get comfortable enough to sleep.

This afternoon, Susan and I will meet again with the palliative care specialist, Dr. Glare. I am particularly interested in gaining a better understanding of the risks that I will now be running if I prolong the dying process. I know that my circumstances could change quickly, with dire consequences; and that the converse is not true. For mere mortals, time's arrow has but one direction.