Medicine is an honorable profession. We meet people at a vulnerable point in their lives — when it comes to cancer, it is often at their most vulnerable. In oncology, care is typically multidisciplinary, and one of the most important advances in my own professional career has been this team approach. To see a patient with my colleagues from surgery and radiation oncology, and the opportunity for all of us to meet with radiologists and pathologists to fully review and discuss, and then to generate a comprehensive treatment plan has made the care of those newly diagnosed patients less fragmented. I also think it’s more reassuring to those patients, who can rest assured that every member of their treatment team has reached a consensus on how best to approach their particular cancer.
I wish this level of knowledgeable, multidisciplinary cancer care extended beyond the boundaries of oncology, but more often than not, it doesn’t. In fields outside of oncology, I find that the natural history of cancer, and more importantly, the successes we have had (and continue to see) in cancer care are not easily understood. Instead, patients with cancer are treated in ways that still make me cringe — as if every cancer is a death sentence and all patients are terminal, especially if one carries a diagnosis of metastatic disease.
I took care of a woman in her 60s with recurrent ovarian cancer. Her disease had just progressed on a third line of treatment, but she still looked and felt well. We had spoken about alternative treatments, but our conversation was grounded in a reality that this cancer would ultimately be the reason she died. I had talked with her about advance care planning, and she was adamant that she did not want to be resuscitated if she was dying. We filled out the paperwork, and we made her “do not resuscitate” or DNR.
We began fourth-line treatment and unexpectedly (to me) she became severely neutropenic. I discovered this only after I was paged from her local emergency room, alerting me that she had arrived with low blood pressure and a high fever — signs pointing towards sepsis.
“How is she?” I asked.
“Well, her pressure is low, but she is conscious. She’s DNR, so we’ve already called it in: she will go to a medical floor, and we will keep her comfortable.”
I was taken aback by this. “Wait — why aren’t you going to support her? She has an infection, and she’s septic. This has nothing to do with her cancer, and it’s reversible. She should go to the unit.”
This prompted a tense conversation with the attending, but I would not back down. My patient and I had not stopped her cancer treatment, and she had just been telling me how much she was looking forward to the next few months. I had an obligation to advocate for her care — care that I thought was appropriate. However, on the other end of the phone was an attending — a very good emergency medicine attending — who did not know her, did not know her cancer, and did not know what we had discussed. He saw a sick older woman with terminal cancer, now with a potentially life-ending condition. And she was DNR. It felt, to him, the most appropriate and humane action would be to keep her comfortable, and let nature take its course.
Finally, I stopped talking about her cancer and stopped bringing up the reversibility of her condition. “Look, this woman was just golfing the other day. She was babysitting her nieces. She has a good quality of life — in fact, she is enjoying this life, and I think she has a lot more living to do. She wouldn’t want to die on a machine — that she is adamant about — but I don’t think it meant she wouldn’t want to be supported through something reversible where there is a good chance she could return to exactly where she was last week.”
With that, he relented and called the ICU. She ultimately was admitted to the ICU, though I continued to have to advocate for her admission there. Fortunately, it was a short stay, and she recovered to her baseline.
We all come to patients with differing perspectives. Oncology is evolving, and those of us privileged to work in this area have seen incredible advances. But for those not in our field, cancer is still a devastating disease, starting at the point of diagnosis. As oncology professionals, we need to continually recognize this gap in understanding, and we can never stop advocating for the best interests of our patients — and more importantly, their wishes. It requires us to be as honest as we can be with them and take the lead in difficult conversations about prognosis, treatments, risks, and yes, end of life. Even as we initiate palliative care early on, it’s important that we do not accept death from cancer as inevitable, or even as imminent. We need to help our patients protect the good days ahead of them.
Don S. Dizon is an oncologist who blogs at ASCO Connection.
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