Of all the sad pronouncements that oncologists deliver, this may be the one that stings the most.
If you were expecting hope from your doctor, how would you react to these words? Would you sit with quiet disbelief, or storm out of the office? Why would putative healers, trained to ravage cancer at every turn, back away from a new opportunity? I recently had to tell a nice patient this distressing news almost immediately after he was diagnosed; in fact it was during just our second visit together. When I walked into the exam room on that day I was stunned to realize that our chance to work together was gone, and at first it angered me. While counseling the family, though, I was overwhelmed by a sense of shame, as if by refusing to treat my patient I was mocking his life. Nevertheless, our discussion led on inexorably to his agreeing to hospice care. What then is the rationale behind oncologists recommending that cancer be allowed to take its natural course?
The answers seem intuitive, but since this decision is difficult to make and can cause great distress to patients and their families, let’s spend a moment reviewing the circumstances under which oncologists recommend avoiding treatment.
“You are too sick to tolerate the treatment.”
With advances in chemotherapy and biological agents appearing almost monthly now, this is the most common reason why we advise no therapy. The risk of not surviving the toxicity of chemotherapy rises, and the likelihood that life will be prolonged falls when patients who are disabled attempt treatment. By disabled I mean patients who because of their symptoms require help with daily activities that we take for granted, such as getting out of bed by ourselves. Another discouraging sign is when patients spend the majority of their time resting during the daylight hours. This decline is what prompted me to recommend hospice care to my new patient.
“Treatment has no chance to improve your life.”
Again, this is a common sense ruling—if a patient is obtunded, demented, bedridden, unable to cooperate with instructions or incapable of understanding the treatment, I won’t proceed with aggressive therapy. This does not preclude certain palliative measures to relieve suffering, such as radiation therapy.
“There are no effective treatments available for you.”
The key word here is effective. One of the quirks oncologists possess is a short-sighted enthusiasm to keep trying new chemotherapy drugs, also known as “Don’t give up the ship!” Such misguided attempts at throwing new drugs at patients, with little chance of response, are better termed “rearranging deck chairs on the Titanic.”
We have deserved such criticism in the past, but now the world has awakened to the value of appropriate end-of-life care. Oncologists, therefore, are obligated to stop treating when treatments have stopped working, and avoid any pressure to provide futile therapy.
One final note—as in all patient care, there are exceptions to the rules. If you were to present with a certain type of cancer, even if you were critically ill, in intensive care, on a ventilator, hypotensive, sedated and unable to receive informed consent, I would still treat you. In fact, with the permission of your family I would start you on chemotherapy today. What is unique about your case? You have a highly curable malignancy, such as Hodgkin lymphoma, one that will die from my treatment faster than it can kill you. Among many others, such are things that make oncologists smile.