Prospects

He’s cheerful as he comes into the room. Almost elated. As if some weight has been lifted.

She’s beside him as ever, buzzing around quietly, solicitously. Her hands move as he moves, but barely touching him. It is as if he were once one inch larger, in every dimension. Probably he was too: more than that perhaps, judging from the unused space in his jumper, his jeans.

‘Thank you’, she says to me as though I have done something kind already. He has sat, she is still hovering.

His smile is as persisting as hers.

‘Well,’ he says, ‘thought I’d come back and give you an update anyway.’

Returning his smile in a way that hides my wary uncertainty about the agenda here, I nod encouragement.

‘Great, I was wondering’, I confirm.

‘He is still losing weight’, she says, tipping her eyes towards him.

‘But I’m eating lots of goji berries!’ he protests cheerfully.

‘They must be doing something?’

She looks encouragingly at him. ‘You’re definitely more alert than you were’, she asserts.

‘But you need to eat a lot more porridge if you want to get back to your running!’

His smile fades as he looks me in the eye. ‘I’ve always been a good runner. Right from when I was at school.’

I look again at his jumper. Maybe it was always oversized? I try to re-imagine his gaunt frame as a lean, toned one instead.

She notices. ‘He said yes to the chemo’, she volunteers.

‘I’ve nothing to lose’, he explains brightly.

‘Can’t even walk to the shop without feeling wiped out nowadays. A year ago I was still running in the hills most mornings.’

So that’s it: they’ve come to let me know their decision. I sense he expects me to be disappointed.

True, I did try to explore the area of his expectations and to open his eyes to the downsides of chemotherapy, especially in his case where the only gain might be measured in weeks. But I did not attempt to dissuade him.

I see the same in those who have got into debt. Before reaching the point where any act feels futile, I regularly see how people behave in ever more desperate ways, trying to restore their solvency. This is a key tenet of Prospect Theory:¹ when contemplating gains we are risk-averse, but when contemplating losses we become risk-seeking. It seems that in medical circles the penny has not yet dropped though: people think in the same way when pondering their health as when pondering their finances.

So, committing to chemotherapy is often the desperate act of a dying person hoping somehow to recover what has been lost. Here, my attempt to mitigate his risk-seeking behaviour has clearly failed. How hard did the oncologist try? Whatever the answer, I am sure the routine of sending all such patients to see one is flawed.

‘You are still grieving for what you have lost.’ I say this gently, merely as an acknowledgement.

He sighs, smile fading, eyebrows rising.

‘I am.’

There is a silence. He runs his hand through the close-cropped hair that stands still across his scalp but which soon will be lost too.

‘I know it might kill me,’ he stares across to the window, ‘but I just feel it’s my only chance to alter the course of events.’

His wife reaches across and grips his hand. She is silent, watching me with dewy eyes. We went through all this with her first husband too. Our experience does not help him though. Gambling like this is a form of solitaire.

• © British Journal of General Practice 2017