A vulnerable cancer patient’s reliance on his oncologist can be extraordinary, and it is not unusual for the patient to look to that physician for advice and counsel on a variety of health-related matters—psychiatric, nutritional, and some unrelated to the primary disease of concern. This role of the “perceived expert” on all matters medical must be handled with tact, realism, humility, and always with graciousness. It’s a simple thing to disavow expertise but, while doing that, to show obvious interest by offering suggestions on some questions and promoting appropriate referrals when indicated. In this day and age of subspecialization, it is important to remind ourselves that we are still physicians and we should attempt to care for the “whole patient.”
Explore this issue:August 2016
End of Life
Importantly, during the final approach to death, the oncologist is often the go-to person for a variety of matters. While many patient concerns can and will be handled by the supporting team, the majority of the questions asked are well within the purview of a mature and receptive oncologist. The patient and family should feel as if their physician is involved with and overseeing almost everything that’s happening, and importantly, the oncologist especially should welcome discussing death with a cancer victim. From a patient’s perspective, who better to talk to about death? With a well-crafted discussion, there often follows an element of surrender to the reality of death, understandably sometimes accompanied by anxiety, but usually without terror. More often, the surrender is followed by acceptance and a sense of calm—in the vernacular of the hospice philosophy, a tranquil comfort, rather than turbulant and rampant fear of the unknown. This passage from realization to acceptance is essential to the willingness of a patient to cease trying to hold their mortality at bay.
What ought a cancer patient reasonably expect of the system, the cancer team, and, especially, the cancer physician? What ought a cancer physician be able to expect of the patient? What are the physician’s responsibilities to the patient? To the family? How much information about the disease is enough, how much is too much, and, importantly, how much is too little? Where do optimism and encouragement end and the gravitas of realism begin? How specific and how graphic should the doctor be? Is pessimism allowed, and, if so, should it be shared with the patient? How forcefully should the case be made for the recommended treatment; that is to say, should the physician attempt to alter the patient’s search for autonomy when they are disinclined to follow physician recommendations?
Because of the natural instinct for self protection, is it justified for the cancer physician to remain emotionally detached, and in doing that, fail to provide an intensity of feeling that might be more helpful to the patient during treatment and even on into the dying process?
What is the cancer physician’s role when treatment fails or, due to the advanced state of the disease, when no treatment is given? How important are quality of life and quality of death and, specifically, what is the cancer physician’s role in the dying process? Is death solely within the dominion of spiritual forces, or is there a place for the physician as a taker of life, that is to say, the catalyst to death. If not an active player, should a physician even introduce the possibility of patient-induced death i.e., suicide? The oath that we have lived by clearly says “no” to the taking of life by the physician, but should this part of the oath be adapted in search of modern relevance? That certainly has happened in several European countries and in four U.S. states (Washington, Oregon, California, and Montana), in which there are laws condoning varying degrees of physician involvement with induced patient death, a high percentage of which are related to uncured cancer.