A PIECE OF MY MIND

The Before

HIS IS THE BEFORE. A MOMENT SUSPENDED LIKE A BUBBLE

floating on a warm summer breeze gently but inevitably toward the ground. I feel the pop coming, an implosion of the very center of your life. Anticipating what this moment would hold, I nevertheless hoped for something different. To be able to eagerly dial your number and shout out the good news to you in a breathless rush. Its not what we thought. Its not cancer. Instead I take a deep breath, pressing each number slowly, cautiously, drawing out the moment before the burst. The burst of your plans and your dreams and your future. I stall for time, asking if this is a good time, are you alone, do you have a pen and paper? You set the phone down and I hear you call to your partner, herd the kids downstairs, step quickly back to the phone, and pick it up. Im ready. I want to tell you to wait. Wait just a minute. This moment, this before is the last one youll have. When I tell you what I have to tell you, life will irrevocably change. The prism through which the light of your life diffuses will be different. How you look at your children will be different. What makes you smile or cry or laugh or weep will be different. Everything will be different. Savor this moment when what to make for dinner is your most pressing concern, when the future is certain, safe, secure, and predictable. Dont leap too quickly into what comes next. Like a life flashing before ones eyes in a split second, multiple possible dialogues go through my mind in the before. I want to be straightforward but not blunt. I want to be compassionate but remain professional. I slow myself down, re-

mind myself that the words Im about to say are ones that Ive said before, many times, but that the words Im about to say are also ones youve never heard before. You wait, breath held in, hands clutched anxiously around the phone, maybe holding your husbands hand. I wait, taking that last moment to make sure that Im ready and that youre ready. I ease us both into it. I start with the warning: Im sorry. You know now. You know what Im about to say. Do you hesitate for a moment, wondering if you should just hang up the phone before you hear the rest? Keeping yourself in the before, knowing that youll fall with the certain words I have to speak? You dont hang up and I am forced to continue. Forming the sounds around words like cancer and prognosis and surgery. You flounder, looking for something to hold on to in the sea of confusion into which youve just been thrust. Each rope you grab to steady yourself comes loose in your hands. Like a tumultuous sea, the diagnosis swirls around you, threatening to pull you toward the endless bottom. I have no life preserver to toss you. All I can offer is my hand, reaching out to hold you up, prevent you from going under until the sea calms and the path clears.
Jennifer Frank, MD
Author Affiliation: Theda Care, Neenah, Wisconsin (drjenfrank@gmail.com). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

A Piece of My Mind Section Editor: Roxanne K. Young, Associate Senior Editor.

2012 American Medical Association. All rights reserved.

JAMA, March 7, 2012Vol 307, No. 9 921