If my grandfather were alive, he would be the same age as Mr. Hendricks. Seventy-eight years old. That’s why when I first met him, he introduced himself as John, but I preferred to call him Mr. Hendricks. That’s how I was taught as one of the ways to give respect to the elderly. The “American” way is to call someone by their first name if you have some level of closeness to them, and that’s what he prompted me to do a couple of times: “Call me John.” But I preferred to abide by the mannerisms taught to me by my upbringing and chose to give him respect by calling him Mr. Hendricks.

He was referred to me for anemia. “You have half the amount of blood in your body compared to what you should normally have. That’s why you always feel so tired and short of breath.” I explained his illness to him. “The fancy word for your disease is myelodysplastic syndrome, but in easy terms, let’s say that if your body were a car, your gas tank would have a hole in it, and your fuel gauge is on Empty all the time.”

He seemed understandably alarmed. “Well, how do we fix it then?” He inquired with cautious optimism. “This is an incurable disease for someone your age. We can give you chemotherapy which may slow it down and buy you a few more months or years to live, but we can do nothing to completely get rid of it.” I responded.

“How long do I have, doc?” He asked the ultimate question. “Most people in your situation will have another year or two to live. With treatment, that is. It could easily be less than six months if you choose to go without treatment.” I answered him to the best of my abilities.

“Do some people choose not to do any treatment at all?” He seemed curious. “Yes. A few people will say that if a disease cannot be cured and if they feel that they have lived a good life and are ready to go, they might choose not to go through chemotherapy.” I explained. He decided to get his treatments.

He came to the cancer center on a regular basis. Within a few visits, he became a favorite among all the staff. Decades of life experiences had turned him into an extraordinarily polite and kind man. He had a remarkable ability to pierce through any interpersonal barriers and get acquainted with the personal issues of several nurses and staff members. This was aided by the fact that he was a handsome man. He was always sharply dressed and carrying his grey hair and wrinkles like a seasoned movie star.

I got to know him more as the months passed by. He went through a bitter divorce earlier in life but then fell in love with Kelly, who was eighteen years younger. They were married now and seemed to have a very happy and content life. Their affection for each other was visible in each word and gesture. Their love for each other was so that upon hearing the news of him having an incurable illness, Kelly could not stop her tears, and although he was the patient, he was the one consoling her and telling her that they would be OK.

His disease responded extraordinarily well to the treatments. He did not require a blood transfusion for months. We would meet visit after visit and talk about how it had already been two years since his diagnosis, and his disease was still not showing any signs of progression. He had already outlived the grim prognosis as it appeared to be at the outset. The three of us chatted at each visit, chuckled at each other’s jokes, and he would give me life advice since he was feeling so well that there were no symptoms to treat, no issues to handle.

One day when I walked into the room, I saw something unusual. He had not shaved in a few days. He looked like he may have lost five to ten pounds. He wasn’t looking as sharp as he always did. I looked at his blood work again, thinking I may have missed something and perhaps his disease was progressing, but everything looked perfectly fine. “Kelly didn’t join you today?” I asked, noticing her conspicuous absence.

“Did you hear about the rare case of a patient dying from Eastern equine encephalitis last month? Apparently, it is such a rare disease that it had to be reported to the Department of Health and was all over the news.” He said. “Yes, of course, that case was discussed in every Grand Rounds in hospitals across the city, but how were you involved with that?” I was still clueless as to why he was trying to change the topic.

“That was Kelly. My Kelly.” His eyes filled with tears. “Oh, I’m so sorry to hear that, Mr. Hendricks. I’m truly very sorry!” I responded, clearly taken aback. “I was the one who was supposed to be old and dying from terminal cancer, but here I am, doing perfectly fine, and she left me. I did not see that coming.” He said. “Neither did I.” I consoled him as best as I could but felt that I couldn’t, no matter what I said.

The next few appointments were difficult. Physically he was still doing miraculously well, but emotionally he was being challenged. Most of his friends had either died or were too busy with their own problems to be able to spend any time with him. He had two children who lived out of state and could not take enough time off to visit him because of their jobs and kids. He would not move in with them because he could not let go of his autonomy. A handful of distant relatives lived locally but could only see him for a few hours each week. He did not want to meet new people and make new friends. “That’s not what is on your priority list when you are my age. People my age have their own issues, and younger people don’t have time.” He explained. He missed Kelly and wanted to tell me her stories at each visit.

Another few months passed. This time he came up with an unexpected request. “Doc, I want to stop my treatments.” I could not hide my bewilderment. “But your treatments have been so successful, and your disease is in such excellent control? Stopping your treatment doesn’t make any sense to me.” I resisted. “I know, but I’m not sure if I have anything left to live for anymore.” He tried to make me understand. “Didn’t you say that some people choose not to get these treatments in the first place? Why can’t I stop my treatments now if that is considered appropriate?” He had a valid question. “Well, I have to make sure that you are not making this decision because of clinical depression, and it would be best if we had a psychiatric evaluation, if you don’t mind.” I shared my concern with him. “Of course, I would do anything you say.” He agreed with me.

I referred him to psychiatry to have him assessed and treated for depressive disorder. I received a note from the psychiatrist that after a careful and extensive mental health evaluation, it was determined that he neither had clinical depression nor a prolonged grieving disorder. He was assessed to have a perfectly normal decision-making capacity.

We stopped his treatments. His disease worsened rapidly. I met him for the last time in the cancer center to transition him to hospice care. As he was leaving for the last time, he shook my hand. “Thank you for all you did for me. Thank you for letting me make my decision. I’m going home a happy man.”

As I was signing his death certificate, I paused for a moment and thought about writing “loneliness” under the cause of death but then thinking that it may not go well with the department of health, I signed the document after filling in the last line with “myelodysplastic syndrome.”

Farhan S. Imran is a hematology-oncology physician who blogs at Did I Ask?