It could be her usual generosity or disquiet, subtly disguised, but she leads by asking about “the kids”. Mine, not hers.

The question from a patient who has known me for years is a reminder that goodwill in medicine goes both ways. I scroll to a photo of my daughter, flanked by her brothers.

“Do you think she looks like me?” I ask as I open her file.

“Your daughter is far more beautiful.”

We both burst out laughing.

Then, to assuage my feelings, she adds, chuckling: “But you’re just fine.”

I realise that my difficult conversation with her will be much more difficult.

Having undergone an array of cancer treatments over 10 years, this woman meets the definition of a survivor. I admire her capacity to appreciate the good in life even when that life seems unfairly punctured by insults. Having always preferred honesty over comfort, she knows that each new treatment offers a little less benefit. Even though I studiously avoid such analogies, she insists she will “fight”.

But lately I have felt a nagging obligation to gently shift her thinking. This is an especially difficult thing to do when people feel well but can still deteriorate without warning. Harder still is a family’s surprise because “no one knew”. No one knew that the disease could become immune to treatment, organs........

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