Difficult Decisions about Continuing Care
Hester Hill Schnipper, LICSW, OSW-C Program Manager, Oncology Social Work
APRIL 22, 2018
It is a beautiful Sunday afternoon, perhaps the first day that has truly felt like spring. There are daffodils blooming in my garden, and, to our astonishment, a young bald eagle landed briefly this morning in our rose garden. After a minute or so, she flew away--taking our breath away. On a day like this, bursting with nature's promises and glories, it is especially difficult to think about end of life decisions. How can one possibly choose to leave this behind?
These thoughts are on my mind anyway because tomorrow morning (hence the reason for writing this today), I am driving once again to Wonderwell Mountain Refuge to facilitate a retreat for women with advanced cancer. I know these we will have these heartbreaking conversations, and we will manage them. We will also laugh and drink wine and gaze the the stars that so fill those mountain skies. I always think of the cliche: How can we be afraid of the dark when we have so loved the stars? But afraid we too often are, and the goal of the next few days will be to try to shrink some of that fear and replace it with a sense of belonging and community.
The article I am going to give you today is from The New York Times by Dr. Bob Wachter, Chair of the Department of Medicine at UCSF and a leader in the field of palliative care. He writes clearly and tenderly about a new struggle in cancer care. Although it has certainly never been easy to shepherd patients gently towards a shift in goals, to honor and respect Quality of Life and comfort rather than pushing endlessly towards a painful treatment that has very little chance of success, it has just gotten harder. As he points out, there is always grief and heartbreak, but usually it is pretty clear when that time has come. Working respectfully and gently together, a doctor and a patient can find common ground and acceptance. With the discovery of immunotherapy (see many previous blogs about this) and individualized medicine that is directed a very specific gene within a tumor, there have been some remarkable successes. It is now sometimes not unreasonable to push forward when, before these therapies, that would have just felt like unnecessary torture. The catch, of course, is that they don't always work. Actually, they don't usually work. The most commonly used statistic is that about 15% of people with advanced cancer will experience a response. But some of those responses will seem like miracles and enable someone to stay on through the daffodils to see the apple blossoms and the roses.
Here is the start and a link. This is worth reading; trust me.
The Problem with Miracle Cancer Cures
Robert M. Wachter
I FREQUENTLY care for patients with advanced cancer. A majority have already tried some combination of surgery, chemotherapy and radiation. Many have landed back in the hospital because the cancer has returned or spread widely and left them in intractable pain or struggling to breathe.
The hospital stay is often a time when patients decide to stop aggressively fighting their cancer, and instead to focus on palliative care and achieving a measure of comfort and grace at the end of life. The moment of transition can be subtle. It’s sometimes signaled by a sweet look from a husband to a wife, a gentle touch of the patient’s hand by an adult child, or two simple words: “It’s time.”
Over the past 20 years, evidence has demonstrated that palliative care decreases pain, improves comfort and even, in some cases, prolongs life a few months. In my experience, conversations about turning to it often begin with patients recognizing that curing their cancer is impossible. Patients sometimes ask for my opinion on this. While the conversation is often heartbreaking, it has rarely been a hard call.
But now it is. And that has thrown a wrench into the way we treat patients with advanced cancer.