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[Catharine]

Here's a link to an excellent article by Atul Gawande in a recent edition of The New Yorker.

Warning: It is not easy reading from the emotional standpoint of someone who has cancer or is caring for someone with cancer, but it is worthwhile if you want to tackle it.

http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande?currentPage=1

- Catharine

[JoeSperrazza]

Catharine,

Thank you for posting this. It is an excellent article.

You warning that it is not easy reading is well deserved. I am very upset after reading it, but I'll get over it.

Thanks again,

Joe S.

[Catharine]

Joe -

Based on your post, I've gone back and added a true warning. I had a hard time with it too, but have always appreciated Dr. Gawande's articles, so I muscled through.

Now, time to do some chocolate therapy, I think. 

- Catharine

[JoeSperrazza]

Now, time to do some chocolate therapy, I think. 

Catharine,

I'm more aligned with Homer Simpson therapy:

Mmmm... Donuts
http://www.tenyeardeal.com/wp-content/uploads/2010/06/homer_simpson_and_donut-1090.png

 

- Joe S.

[Terryl]

Thank you so much for the link to this article.  It was both enlightening and moving. 

[Dr West]

Catharine,

   Thank you so much for posting this link.  I went to medical school with Atul Gawande and have followed his career over the years.  To his great credit, not only has he developed a skill of being able to write in a very compelling, sensitive way (in a recent live talk in Seattle, he explained that he was a pretty poor writer through college and medical school, improving his style largely in the last decade), but also showing the courage to tackle some of the most important and vexing problems our medical system faces today.

   This is a topic so important and with so many layers that, even as long as this piece was, it could have been ten times longer.  Costs generated by our societal inability to confront harsh realities are crippling.  Most patients are referred to hospice services an average of mere days before their death, which is far beyond the time when hospice could be of most benefit, but the conversations are difficult and it is easier, and financially incentivized, to treat to the point that a patient can no longer get out of bed.  It takes great communication skills, as well as more courage than most physicians really have, to face these hard discussions.  Patients and families are also afraid of missing opportunities or "giving up" too early, to the point that we often refuse to acknowledge the elephant in the room until it's nothing short of inescapable.  And the media dedicate their health beat sections largely to misleading promises of a future breakthrough and remarkable stories that unfortunately represent the extreme exception rather than the rule.  We live in a world where people mistakenly believe that "there must be something we can do!", that the cancer will respectfully keep its distance if a person is a VIP, ate a healthy diet, or is young with small children.  But it's generally cruel and indifferent, and cancer biology doesn't care about these things.

   Though I feel that I confront these hard discussions as frequently as anyone and as carefully as I can, I am like Dr. Gawande in being complicit in sharing some lies of omission and sometimes over-emphasizing hope.  I don't think it's possible to navigate these waters without being above criticism.  Just as Dr. Marcoux and many other experienced physicians were unable to address the difficult challenges of expectations of Sara and her family, we can all be swept away by the strong current of emotions. 

   But I'll admit that I cringe when a family member or patient with metastatic cancer says, "Doc -- we're going to beat this!!" and "We're never going to give up!!", because I've seen how things turn out, and I think it's unfortunate to think that the accepting the reality of a situation represents giving up, especially when postponing that recognition means missing out on better comfort, communication, and preparation for a patient and their circle of support.

   Sorry for the meandering.  This article represents the struggles and our own ambivalence that we face every day.

-Dr. West
 

[recce101]

Catharine, many thanks for the link. Because of your warning I waited until everyone else in the family was asleep before starting the article, but I found it to be satisfying and, in a way, even comforting. It illustrates not only the wide range of beliefs and emotions connected with the end of life, but also the amazing dedication and compassion which so many medical professionals bring to the issue every day. Mahalo and Aloha,

Ned

[myrtle]

Excellent article.  Thanks for sharing Catherine.

Myrtle

[Laya D.]

I agree. . .the article was very good and very well-written, but EXTREMELY difficult to get through. . .

Thanks for posting it,
Laya

[kej]

Hi,
I also waited until everyone else was asleep.

Thanks for recommending this article. Very well written and much food for thought....

[Catharine]

Terryl, Dr. West, Ned, Myrtle, Laya, and kej -

You are most welcome. I hope you also engaged in some post-article chocolate therapy, or, as Joe recommended, HomerSimpson therapy (doughnuts!). 

Dr. West -
Your thoughtful comments from the physician's perspective are most appreciated. They are not at all meandering. What a class that must have been with both you and Atul Gawande!

- Catharine

[JimC]

Catharine,

Thanks for posting this article. As you said, it was very difficult reading. Those who stayed up late to read it are a lot tougher than I am; if I had done that I still wouldn't have slept a wink. I waited until today to read it, so that I could lose sleep tonight instead.

I'm wondering if we're just asking too much when we expect oncologists to handle both the treatment aspects and the psychological/emotional aspects of an incurable cancer diagnosis. I thought our oncologist did an incredible job with both those tasks at our first meeting, and our cancer center does have counseling available, but perhaps what is needed is an initial "pre-hospice" session in which a trained specialist could raise some of these issues before the treatment train really gets up a head of steam and becomes impossible to stop. You wouldn't want to use the word hospice, since that would have too many negative connotations at the start of therapy, but it might be an opportunity to lay some groundwork so that the eventual questions about ceasing anti-cancer treatment and utilizing hospice wouldn't be as difficult.

Jim

[JoeSperrazza]

Catherine,

I've kept the article. God willing, it will be a long time until I need to read it again, but it was superb. Thank you again.

Jim,

Your comments on "pre-hospice" are thought provoking. Perhaps some centers do offer such services for those whose prognosis is poorer than others. I was incredibly stressed by my wife's initial diagnosis, so much so that I'm glad CSMC had a social worker as part of our "team", and a couple of sessions with him helped me find help elsewhere. I suspect that if conditions had warranted it, he would have introduced hospice to us. However, had a "hospice" representative or discussion been a mandatory part of our care there, I might have really lost it.

Joe S.

[Catharine]

Jim -

That idea of an initial counseling/pre-hospice session with a specialist is a good one, and should occur before the "treatment train" gets too far down the track. I was referred to my HMO's social worker just after diagnosis and was fortunate to get a wonderful person, since retired (good for him, but I do miss him), who provided a lot of information, including a flyer on palliative care. He presented the flyer as part of a general information package, which made it more palatable at that time and opened the topic had I been ready to discuss it. (I wasn't.)  That said, his counseling really helped me get through the first several months.

- Catharine

[JimC]

Joe,

I know exactly what you mean; no one wants to start talking about hospice at the time of diagnosis and I would have had the same reaction you describe. But whether it's at that time or some subsequent point (perhaps when the cancer starts to progress after treatment but before there are no treatment options remaining), some specific counseling might help patients and their loved ones have a conversation about what to do if things aren't going well so they can be prepared to address the question of ceasing treatment, hospice, etc.

The problem is that everyone goes into treatment trying to be hopeful, whether it's for a cure or for prolonged survival (although as the article points out, most of our expectations for prolonged survival are for 10 to 20 years which really amount to hopes for cure). At some point those expectations may have to change, but that point may not be easy to determine; we always have that hope that the next treatment will work where others have failed, and all we need to do is read of a few examples of that happening to sustain that hope. And (as Catharine just pointed out while I was typing (slowly) and thinking (even more slowly!), the earlier and more "theoretically" that conversation occurs, the easier (relatively) the eventual decisions may be.

Jim