It’s a hard question, especially for a surgeon. We surgeons like the instant gratification of going in and fixing things. As a surgeon who also gives chemotherapy, managing the end of life is really hard for me in a fundamental way: it’s (in a strange and very personal sense) an admission of failure. The patient hasn’t failed the treatment; that’s a given. The chemotherapy and the surgery have failed; but doesn’t that also mean that I have failed? Even though we all knew that the cancer was advanced and the chances for long-term survival were low, I have failed. For me, this is the hardest part, to look at my patient and say “I’m sorry, there is nothing more I can do.” (It is so hard, in fact, that many doctors give chemotherapy far too close to the end of life.)But really, it is just not true that there is nothing more I can do. I may not be able to surgically fix the bowel obstruction or to shrink the cancer, but there is a lot for me to do at the end of life. There is of course the management of symptoms: pain, nausea, constipation, fatigue, depression. But beyond that, there is an advantage to being together with my patient in the same room. Just taking the time to sit and talk with a patient and family, to hold a hand, to share photos or an anecdote, is meaningful. Even when my patients are on hospice, many (not all) of them still come see me monthly to check in. They get cleaned up and dressed and out of the house, and we sit in my office or exam room together and we talk. We talk about their symptoms and quality of life, we talk about their families, their new grandchildren. Sometimes we talk about my life and my children (they worry about me!).
Transitioning someone to hospice and palliative care is not so much a failure as a change in focus and direction. And in this process, I’ve learned to make sure that my patients know I am still there for them, that I will still take care of them, that they still belong to me and that I belong to them. I invite them to come see me monthly even after the transition to hospice (if they are able and if they want to come) so that they know I am still involved in their lives. In a big way, this helps both.