Dealing with Death

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
G

ghgi8

Senior Member
15+ Year Member
Joined
May 27, 2004
Messages
162
Reaction score
0
A search on this subject yielded few results, I'm sorry if it has been discussed previously....

As a recent discoverer of this amazing field I am doing all I can to guage how it fits for me. One of the main, and possibly only, drawbacks to radiation oncology seems to be the sad occasions when a _______ (fill in the blank....young, not ready to die, incredible person, anybody) patient comes under your care. I was hoping to get some feedback from the senior members on how, and if, you ever learn to deal with this. Is the ability to cope an attribute I can acquire or should I assume that my first emotional reactions in this realm will dictate all others? Sometimes I feel as though I would have a lot to offer my patients in such a state but I question my strength to not internalize things too much. Any words of wisdom are much appreciated.
Members don't see this ad.
 
Here are stephew's thoughts on the subject from a few years back: http://forums.studentdoctor.net/showthread.php?t=95521

I tend to agree with her. As an IM intern rotating on the Oncology service I saw several pts with Stage IV cancer die under my care and was actually involved in the codes a few times. When we see pts (generally speaking) they tend to be stable. Also, as stephew said, we can offer a bit more in terms of palliation than other oncologists which can significantly increase a pts quality of life.

As to dealing with terminal pts, each person copes differently. I tend to be optimistic for the above reasons - we are doing the best we can with the current technology and understanding to improve the pts QoL. Also, by spending time with pts in terms of answering questions, counseling and education you can make them feel better. Often a pts fear is fear of the unknown -- (e.g. prognosis, will it hurt, etc.)
 
Thanks for your response. I am wondering whether I am exaggerating the magnitude in which this really is an issue for radiation oncologists. I think one of my other fears stems from the above discussion....

In the future, how often will I have to deliver bad news? I have read on this forum and other sources that the profession is mainly considered a consult field. In which case I would think that patients are properly staged and informed of that stage and its implications for treatment and/or palliation prior to that consult visit. I imagine that there are cases where the patient wasn't properly imaged/biopsied prior to this consult and they subsequently become upstaged, thus leading the radiation oncologist as being the bearer of bad news. But, I guess the question I'm getting at is...what are some other circumstances in which we would have to deliver bad news?
 
Members don't see this ad :)
We don't deliver bad news very often. The primary diagnosis of cancer or of a recurrence is generally given by the pts medical oncologist or (rarely) PCP. When they see us they generally have pathological/radiographical confirmation. Once in a while, they may be upstaged if our in-house pathologist or radiologist interprets the outside data differently.

Of course, when we f/u pts who were already treated by us recurrence is a possiblity. In this case we may have to deliver the bad news. However, you can't usually irradiate the same area twice if it is a local recurrence in which case we will refer them often to our surgical colleagues.

Once in a blue moon, I have seen pts who were not even properly informed of their cancer diagnosis and are not quite sure why they are seeing us. Such situations can be uncomfortable.
 
One major issue that will continually come up is in-house consultation patients that have not been informed about their diagnosis (i.e. new brain lesion and a mass in the lung that has not been biopsied). A lot of times, you are supposed to see the patient within 24 hours of consultation, but at that point, they have not seen an oncologist, not been told of their diagnosis, and do not know what is to come.

In this case, the best situation is the talk to them and tell them the worst case scenario, in my opinion. Talk to them that they may likely have cancer and it may likely have spread to their brain (bone, whatever). Talk to them about the current stage IV treatments, that there is still time to intervene even though they have advanced disease. It is gratifying to be the first to talk to the patient about their diagnosis, possible treatment options, and prognosis - not too many docs know as much about this as we do. If you are wrong and their brain lesion is an abcess and their lung mass is pneumonia, you can give them good news (rare!).

The other situations of recurrence discovered on imaging or your own exam, well that's tough. It is the hardest part of our field, but again, very gratifying in a career sense. Many oncologists say that treatment failure is the worst part about practice, but I don't agree. We can provide advice/counseling, compassion, and sometimes even treatment. I'm telling you - very little in medicine is as gratifying to me as relieving their pain without using opiates or nerve blocks. Just a few x-rays, and someone can sleep at night or swallow again.

I think radiation oncology is a palliative care field. About half you treat palliatively at diagnosis. About half you treat curatively, but many of those fail. And it's your job to make them feel better or refer them to someone who can. It's not so bad - some of my best recent patient relationships have been palliative cases. Many metastatic prostate and breast patients become chronic disease patients because of the long natural history of disease and the success of systemic therapies, and it's almost nice to see them in follow-up after you treat their bone met or brain mets ... and they actually look good.

It's tough. I still can't stop thinking about certain patients (my 30 yo rectal CA patient with mets to his pelvis, perineum, and extension into his gluteus) and wish I can do more. I just want to make him feel better and I try to do so, but can't; but there is so many that I do make feel better. And that is really nice. So, in a few words, we are oncologists and palliative care docs, all in one. It's a broad spectrum of patients, but one I think I'm lucky to treat. Don

-S
 
Gfunk6 said:
Once in a blue moon, I have seen pts who were not even properly informed of their cancer diagnosis and are not quite sure why they are seeing us. Such situations can be uncomfortable.
Click to expand...

I second this. But while one would think this should be a rare "once in a blue moon" occurrence, I have seen it happen a startling number of times.

Some patients have no idea what they have ("I have cancer?!?!") Some say they were told they have a "tumor" or a "mass" or (INSERT YOUR PREFERRED EUPHEMISM HERE) but they didn't know that tumor = cancer. Either they weren't told or it didn't sink in or it's denial. Probably 33%/34%/33%.

It's very disheartening when this happens and it's always awkward to begin a consultation by dropping a bomb on them like this.

As for what the original poster asked, almost never do we have to break the bad news of a cancer diagnosis to a patient, but we may have to tell a patient that their cancer has returned or spread.
 
I find that, many times, I am the first to have a frank discussion with the patient about exactly what their cancer diagnosis means (re: prognosis). I have also seen a few consults who have not been told they have cancer (not suspicion of cancer, biopsy proven cancer) when I am there to evaluate them for whole brain radiation. I think both of these situations are a result of doctors who did not want to deliver bad news ("the oncologist/radiation oncologist will tell them"). Being able to deliver bad news is an important skill, and a necessary one in any field of medicine.
 
My experience closely resembles that of Brim and Indy. I guess it shouldn't come as a total surprise; it's human nature to want to dance around a dismal prognosis, and it's a feeling that doesn't spare even oncologists. I agree with the general sentiment that this is a time when you can be of tremendous service to patients, not just from a therapeutic standpoint but from an overall care standpoint. The things Simul alluded to, the opportunity to communicate with and provide compassion to these terminal patients is a very important and fulfilling element of our specialty. Any applicant to the field should give serious thought to their comfort level with this aspect of patient care; probably moreso than their perceived prowess (or lack thereof) in nuclear physics!
 
Thank you all very much for your insight. Does anyone have any tips for confronting the issue? I'd like to pick up a few novels to help paint a perspective....does anyone have any personal favorites? Hope you all have a great week.
 
The best piece of advice I can give is something I actually learned while working in the funeral business: it is not what you can do that the families (and in healthcare, the patients) will remember most, but how you do it. Sometimes the cases you have the greatest impact upon are those where your clinical skills are for naught.

I don't know of any good novels, but one of the textbooks we were required to read in mortuary school was called "The Last Dance: Encountering Death and Dying" and it was a pretty interesting read. It was enlightening even though I had worked in critical care medicine for nearly a decade prior to temporarily shift career fields due to burnout.
 
I did and "end-of-life issues" elective as an MS4, and the book that served as the major generator of discussion was "Dying Well" by Ira Byock. Dr. Byock was instrumental in bringing hospice into Montana, and does a very nice job framing some of these end-of-life issues within a number of patient vignettes.
 
G'ville Nole said:
My experience closely resembles that of Brim and Indy. I guess it shouldn't come as a total surprise; it's human nature to want to dance around a dismal prognosis, and it's a feeling that doesn't spare even oncologists. I agree with the general sentiment that this is a time when you can be of tremendous service to patients, not just from a therapeutic standpoint but from an overall care standpoint. The things Simul alluded to, the opportunity to communicate with and provide compassion to these terminal patients is a very important and fulfilling element of our specialty. Any applicant to the field should give serious thought to their comfort level with this aspect of patient care; probably moreso than their perceived prowess (or lack thereof) in nuclear physics!
Click to expand...
I agree entirely with Indy, Brim and G'ville Nole. During residency, a year in academics and now in community practice, this issue comes up again and again. If it isn't breaking the diagnosis to the patient, it's informing him/her that their tumor has returned. Compassion, honesty and careful listening to your patients are much more important parts of your training than any residency program currently I know of provides in any formalized way. Some people have a gift for an empathic approach, but it is also learnable and can be improved with practice.
 
You must log in or register to reply here.
Next unread thread

Similar threads

scarbrtj
Into the Valley of Death Rode the 600
Replies
26
Views
2K
RollTideRadOnc
R
SneakyBooger
Death By 1,000 Clicks
Replies
3
Views
992
RANDO_Phantom
R
L
Urgent: Online Death Registry
Replies
5
Views
1K
SRC1987
S
Narmerguy
Coping With Death
Replies
6
Views
3K
Narmerguy
Narmerguy
R
Aspirin Use and the Risk of Prostate Cancer Death
Replies
9
Views
2K
subatomicdoc
subatomicdoc
Top