Saturday, January 1, 2011

Discussing cancer treatment with the terminal patient,

“Are you giving up on me?” My patient looks at me severely. “There must be other treatment options! Aren’t there some experimental drugs out there? I have beaten this cancer twice before. Are you saying that I can’t beat it again?”

No one can ever know with absolute certainty whether my patient’s newly recurrent cancer might miraculously disappear with one more treatment. His recurrence, however, has developed very quickly and is growing very rapidly. New cancer nodules are developing weekly. I have never seen a patient with a cancer this aggressive have a meaningful, sustained response to further treatment. The research literature confirms my impression.

It is always difficult to know what to recommend. Although “no further treatment” is always an alternative, I routinely run through all of the options, reviewing whatever is available, and hoping that we land on the combination that offers that improbable, one-in-a-thousand cure. However unlikely, we sometimes set up appointments and hope for the best.

Today, though, my sense is that it is time to focus on new goals.

The decision not to pursue more studies and more treatment can be very, very difficult. Surgeon and journalist Atul Gawande in an essay in The New Yorker entitled “Letting Go,” writes about how difficult it can be for physicians and patients to halt cancer treatment as the end of life draws near. The dilemma, he concludes, “arises from a still unresolved argument about what the function of medicine really is — what, in other words, we should and should not be paying for doctors to do.” In Gawande’s view, the profession should equip and supply doctors and nurses “who are willing to have the hard discussions and say what they have seen …”

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