As oncologists we are justly proud of the real advances we have made towards a cure of the many cancers that afflict our patients. But we also know that caring for those afflicted too often involves life’s endings. Health professionals caring for dying cancer patients bear special responsibilities that few outside the field ever contemplate, or understand. I have always found these discussions the hardest part of my practice, my own sense of inadequacy (there is no other word for it) mingling with my patient’s sense of impending mortality and the palpable grief of the family.
My thoughts turned to this subject after reading an exceptional piece of reporting in the August 2, 2010, issue of the New Yorker magazine. Dr. Atul Gawande has emerged in recent years as one of the more thoughtful observers of the medical scene. His most recent effort, entitled “Letting Go: What should medicine do when it can't save your life?", is worth your time, and should be required reading both for oncology fellows.
One of the more nauseating aspects of the recent health care debate was the demagoguing of our end-of-life discussions with patients as “death panels,” suggesting a monumental level of either cynicism or ignorance by our politicians. This disgraceful claim resulted in the elimination of Medicare payments for doctor’s appointments to discuss living wills, health care directives, and other end-of-life issues. There is something severely dysfunctional about a system that rejects honest discussions with the terminally ill. These discussions, far from “pulling the plug on grandma,” empower patients when they are at their most vulnerable. I hope that we will be able to re-visit this policy issue in the future, after current partisan passions have cooled.
ASCO has been active in this area for many years. To name but a few initiatives: 1) Our Cancer.Net website provides patients valuable resources on end-of-life care, including sections on palliative care, advance directives, caring for a terminally ill child, and hospice care. 2) Our educational and scientific program sessions at the annual meeting regularly discuss issues surrounding the care of the dying cancer patient. 3) The “Art of Oncology” series, ably edited by Dr. Charles Loprinzi in the Journal of Clinical Oncology, looks closely and sensitively at the concerns of patients and physicians in end-of-life settings. 4) ASCO University has learning modules on symptom management and palliative care, as well as on the art of communicating bad news. 5) Palliative and end-of-life care are part of the ASCO Core Curriculum for oncology trainees.
We are all mortal, patients and physicians alike. We who labor in the vineyards of cancer care are immeasurably enriched by our interactions with dying patients, by the courage, fortitude, grace and (yes) humor that they demonstrate in the face of their mortality. That we can help make those last days something better is one of the more valuable and honorable things we accomplish. ASCO will continue to provide resources to patients and their physicians in support of this goal.