Reassurance Revisited

Reassurance Revisited

Robert E. Fisher, MD

Jan 06, 2014

Perhaps the most evocative essay that I have ever read is David Steensma's piece entitled "Reassurance" in the Art of Oncology section of the JCO, published in August 2004. Dr. Steensma writes an emotionally and visually powerful essay regarding his experience providing a consultation to a new mother in her twenties confronting advanced (and soon to be fatal) cervical cancer. Dr. Steensma relates how contradictory it is for us to offer patients and family members "reassurance" in such hopeless cases, and how we are often fooling no one, including ourselves in the polemics we recite to patients daily, out of habit and convenience. Dr. Steensma's essay is well worth the five minutes of your time to read today, and can be accessed here, but please do come back to my essay once you have read this archived article.

I have thought of Dr. Steensma's essay frequently over the past decade and have provided a copy of the essay to many colleagues as a "must read." I think the essay would lend itself to required reading in an Oncology Fellowship training program. I have frequently realized the irony of our clinical language since reading this essay and have wondered how genuine my words are to patients and families in similar dismal situations.

However, a case I was involved with provides a different perspective on the false "reassurance" that I have, at times, felt guilty about delivering. The encounter involved an elderly gentleman with recent imaging that documented an advanced malignancy, as yet undiagnosed, and clearly bearing a poor prognosis in this patient with a declining performance status. The situation was complicated by the fact that this patient’s wife had Alzheimer's dementia, and the patient was clearly her caretaker, despite his declining health.

The atmosphere of the consultation was emotionally charged in an over-packed exam room filled with appropriately concerned family members, clearly addressing the whole of the situation for the first time at that moment. What unfolded next in that hour long discussion was the collecting of a consensus among family as to the goals and priorities to be considered in the work up and treatment planning for this gentleman in a complex social situation. Ultimately, after a biopsy that showed an undifferentiated carcinoma, the patient and family all came to agree upon a palliative care approach as the best solution for the patient and his wife.

What I came to realize, in light of Dr. Steensma's essay, was the fact that despite the dismal outcome that I relayed to the patient and family, all members of the family were deeply appreciative of the clarity and compassion of our several discussions. Though the family had known bits and pieces of the father's situation, they never had a chance for an honest, cogent discussion until we all met at the time of the initial consultation.

Throughout that series of encounters, I provided "reassurance" that we would make a diagnosis in a painless manner, consider treatment options, and consider what was best for all given the extenuating nature of the family situation. Without disrespect to Dr. Steensma's essay, I have come to realize the tremendous value we provide to society by our approach to sorting out these difficult issues in our profession. We often provide that focal point of discussion in a person's life that is life-redirecting and frequently long remembered by family members, long after the patient has expired. That is often more valuable than a brief extension in survival marked by considerable toxicity of treatment.

Each time I re-read Dr. Steensma's essay, I am humbled by the limits that we can offer our patients and their families with their serious illnesses. Yet, this recent encounter gives me a new perspective in what we provide in our profession. I witness the hugs given by our office staff to patients and families on a routine basis in a genuine gesture of concern and compassion, on a daily basis. I am sure the same occurs in your clinical setting, too. However, I feel more at peace knowing that we can reassure ourselves and our patients that we offer direction and leadership when a cancer diagnosis creates a family or personal crisis.


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L. Michael Glode, MD, FACP, FASCO

Jan, 12 2014 1:51 PM

Somehow (could it possibly be that I don't read every issue of JCO from cover to cover???) I had missed the beautiful essay Dr. Steensma provided and I greatly appreciate Dr. Fisher's commentary and reference. Far more often than we would like to admit, our greatest contribution to patients may well be the compassion as well as clarity we can bring to their situation. I am sure that I sing off key more often than I should in citing the hopeful research progress that will not likely reach everyday practice for months or years. A thoughtful hug to a patient or family may be the best form of "personalized medicine" most of us will ever deliver.

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