Yet knowing how way leads on to way,
I doubted if I should ever come back.
Robert Frost, The Road Not Taken, 1915
Last week I had the unpleasant task of informing a patient that his chemotherapy was no longer working. It was obvious that numerous new nodules had appeared on a follow-up CT scan; this matched the rise in his serum tumor marker. True, he had enjoyed an amazing year-and-a-half of essentially no symptoms from his cancer and no toxicity from his chemotherapy. Part of this was due to good luck, I thought, and part of it due to the fact that his tumor shrank tremendously on treatment (or is that just another manifestation of luck?). Now his cancer was growing again and I could see no reason in continuing chemotherapy. The question was (as it always is in my profession) how do I explain this to my patient in an honest but nonjudgmental manner? How do I give him this bad news without appearing callous or inappropriately pessimistic? What do I say if he asks me about trying a different treatment?
Madonn', what a crummy job this perdente has! Hey wait a minute - I'm not Italian, and this occupazione happens to be my life's work! This is my responsibility, and I can't just spew out a string of piffle and expect my patient to sing my praises to the angels.
I suddenly had an idea (Rendiamo Grazie a Dio!), and phrased my message as follows:
"You've been coming to this office every week for 18 months to take chemotherapy and have had an amazing journey - a successful journey until now. Now you have come to a giant sign in the road that says "STOP," a sign placed there out of respect for you as a unique individual, a sign that gives you the right to discontinue your treatment with no questions asked and with all the support you deserve from your doctor. It would be wrong for me to urge you to drive through this stop sign and continue on with this particular chemotherapy, but I can't prevent you from choosing to extend this strange and singular journey by continuing on with some other treatment, perhaps from another oncologist. That is your decision.
"What I can do is to make sure you understand the consequences of running this stop sign. If you end your treatment now, knowing exactly where you are, you can prepare to live the rest of your life in familiar territory. If you choose to drive on, you will enter uncharted lands where no doctor can predict what adversity lies ahead. The decision is ultimately yours."
"Doc, I'm grateful to you for all you've done, but I'm tired of taking chemotherapy and ready to quit it. I understand what you're saying and I'm stopping at the stop sign."
We walked out of the room together and shook hands, two travelers on separate journeys to the same destination.
I shall be telling this with a sigh
Somewhere ages and ages hence:
Two roads diverged in a wood, and I--
I took the one less traveled by,
And that has made all the difference.
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I always try to get a copy of my CT scans before my oncologist does. I can read the report as well as he can. It is, after all, still English.
Your style is a little different than my oncologist. I prefer the straight talk instead of things like stop signs.
I'm coming up on my 1-year anniversary for chemo on lung cancer. I asked my oncologist today and he said I am exceeding expectations. We've gotten used to each other and he knows I am determined to beat this thing by shear determination.
I have decided that failure is not an option.
Thanks for the goosebumps, Doc.
I just ran a serious stop sign, oncologist strapped in firmly beside me. Not ready to quit my journey... Peace and contentment to your patient and yourself. Personal decisions made with full knowledge are sometimes the best we can do.
How does it happen? Is it something that came up out of the blue and broadsided your patient, or is it something that builds up over many months? If it's been building up over many months, your patient probably had a good idea that it was coming. If/when my doctor has to have that talk with me I hope he just comes out and lays the cards on the table and then understands that I went into shock and only heard a third or a fourth of what he said after "the chemo is no longer working." And I don't think that I understand the "non-judgemental" part of the message. Even if he's a smoker with lung cancer, he doesn't deserve this.
Another most thoughtful and insightful post.One of the greatest gifts a healer can possess is to know when and how to say to his patient that "enough is enough" already.I cringe at the thought of some of the stuff I've participated in as a nurse in the name of healing or "salvaging" a patient when it was abuntdantly clear that such efforts would be in vain. It takes great courage and strength of character to do what you do in the most compassionate and sensitive manner possible.You are truly a gift from God and I'm so thankful for you.
You have the most difficult and rewarding job in the world. My experience is that every patient has unique information needs. Some prefer facts, others opinion, and others metaphor and symbolism. Then there are those who would rather not know. It takes a wise physican to determine the difference.