Cristiano Ferrario, an oncologist at the Jewish General Hospital in Montreal, with a patient

The care for life: "I don't detach"

Cristiano Ferrario is an oncologist in Montréal, in Canada, where the law allows euthanasia. In the midst of diagnoses and treatments, the discovery of “a trust that sets people free even in illness.” His story in the April issue of Traces.
Anna Leonardi

“My work is truly beautiful because it helps me to remain alive.” The words of Cristiano Ferrario, 47, an oncologist at the Jewish General Hospital of Montreal, are surprising. In the hospital he is famous for his powerful laughter during office visits with his patients, notwithstanding their grave diagnoses and awful treatments. But even in front of the anguish of the terminal phases, his work does not frighten him. He is often asked how he can detach from all that pain at the end of the day. He says: “Easy. I don’t detach. I bring my patients with me, with their questions and suffering, into my moments of silence, into conversations with friends, into the things I do. I allow them to continue challenging me and to keep the wound open. This helps me greatly in living my life.”

Being a physician in Canada has become a bit like moving on a highway interchange full of exits, ever since a 2016 law allowed access to euthanasia and assisted suicide for people whose death is “reasonably foreseeable.” If a patient meets the requisites, and after evaluation by two physicians, she or he can receive MAID (Medical Assistance in Dying) within a few days. In 2023 the law was broadened to include people with mental illness, encompassing those in a situation of particular vulnerability, such as the destitute, the disabled, and drug addicts. “In Quebec, seven out of one hundred deaths result from MAID,” Cristiano recounts. “These numbers show how endemic this phenomenon is; it has entered into the DNA of the country. We are the first in the world, even ahead of Belgium and Holland.”

The shrine dedicated to St. Joseph in Montreal, on Mount Royal hill (Unsplash/Adrien Marchetti)

The time between request and execution is brief, often shorter than the time needed to obtain other services, such as palliative care. “What happened to a patient of mine was a shock for me. Just five days from his request, he received MAID. He spent those last days closed in his room, without seeing anyone. It was impossible to understand whether he was in pain. He didn’t even speak with his wife anymore, because he wanted nothing to interfere with his decision. I still wonder how much he suffered ‘in order not to suffer.’”

However, many of his patients seek out a dialogue. Cristiano sees them for follow-up visits every three weeks. “This is a fundamental moment in their treatment, not something extra. We look at their exams and test results, evaluate their general condition, and also talk about all the needs that arise in their particular situations. One day a patient and her husband came to my office. Both were very anxious and burdened by the chemotherapy. From the oncological point of view the situation was going well, but she was depressed and had begun to have doubts. ‘Doctor, is it worth facing all this? I don’t know if I want to continue. My husband can’t deal with it anymore, either.’” Cristiano was surprised by her question, and said, “You’re responding well and the illness still allows you to do many things. There’s a world of occasions that can still make you two happy.” They spoke at length about how their days go, their children, their home. Then Cristiano added, “Certainly, some things have changed in the last few years. But we have to detach ourselves from all those images we have of ourselves. Don’t think about how you were. Let’s look at what you have now.” He feels wonder in front of the sick. “Each time, I can either greet them thinking they are poor wretches who are victims of a sick joke, or be amazed they are there, waiting for our meeting to travel part of the road together.”

During one weekend when he was on call, a patient had unexpected complications. Ferrario did not know her clinical history well. He wanted to speak with her husband and he put in a call to the physician who was caring for her. When he finally had them in front of him, he outlined the situation. Her husband, a practicing Muslim, interrupted him. “Doctor, God will take care of her. You do everything possible.” Cristiano was uncomfortable. “We were at a fork in the road. We had to evaluate, in the interests of the patient, how far we should try to keep her alive, and at what cost.” He gave her antibiotics and painkillers. But her condition had become so grave that he wondered whether it was truly useful to put her on a ventilator. “It’s a dizzying situation. You would like to have mathematical certainty, but it doesn’t exist. You have the protocols and years of clinical experience but are always aware of all of the risks of the available choices. You can only look attentively at each detail in order to understand what is happening in that life, and what you can do as a physician and a man.”

As the hours passed, Cristiano shared every action and reflection with the husband. The fact that her condition had deteriorated so rapidly gave them notime to prepare. “I had to do with him what we usually do in months and months of appointments, where we prepare to face those moments without being trapped by feelings of guilt or by instinctive reactions.” The husband changed, passing from an interventionist stance to a softer one. In the evening it was decided not to intubate the patient. “The existence of God was no longer an axiom from which we, mechanically, had to wait for that life to be saved. Instead, God’s existence was the given fact that put us into the position of wanting to know what was happening to the patient and to serve it.”

This is the “gift” that illness almost always gives. “It strips away our false impression that we have everything under control. In fact, often after all the ‘battling,’ people who recover from cancer fall apart because they neither want to nor can return to the life they had before the illness, with the false illusion of having control over every aspect of life. Instead, some reach the point of desiring not to lose that trust with which they learned to look at things and that made them feel free, even in their illness.”

Marie received her initial diagnosis when she was only 27 years old. Following a devastating course of treatment, the tumor seemed to be in complete remission. But two years later, there was a recurrence. Marie refused to accept it and wanted no discussion of treatments. The physicians in her ward tried to encourage her with numbers and statistics, but she felt unable to face it all again, the hair loss, the nausea, the exhaustion, the swelling of her face caused by cortisone. Cristiano’s colleagues asked him to try to convince her. It was the afternoon of Christmas Eve when he entered her room. “I introduced myself and we chatted. From her window you could see the beautiful church of Saint Joseph, on the hill in the center of the city. I told her she was lucky to be able to see the prettiest church in the city. She smiled at me.” Cristiano returned to her every day, sometimes just sticking his head in the door or having a little chat with her mother. Then one day, Marie was the one to bring up the question of a treatment regime. “She wanted to understand the various options and their side effects. I listened to her fears and tried to encourageher. I explained that if she were treated, she could return to walking. To make her laugh I said that if it went well, we would walk together up the hill to the church of Saint Joseph, and that I’d start training.” Marie decided she wanted to try again. The treatment worked, and she is better. After a few months, she and Cristiano climbed the steps up to the church on top of Mount Royal. Cristiano could not explain Marie’s change of heart. “Why did you say yes to me? After all, I proposed the same treatment my colleague had.” Marie said in no uncertain terms that it was “because I looked the other doctor in the eyes and saw he wasn’t happy. I couldn’t trust him. My fear was too great. In the hospital I scrutinized all the doctors who came to talk to me, until I met one for whom the problem was not dying, but living.”