Monday, January 29, 2007

doctor patient relationships - Your Doctor and You - With Cancer, With Hope, Tenth in a Series

While there are several chronic diseases more destructive to life than cancer, none is more feared.”

Charles Mayo, MD, Annals of Surgery, 1926

You passed your 50th birthday sometime ago. You were looking forward to a prosperous middle age and secure retirement. But suddenly you were diagnosed with cancer. The very word “cancer” filled you with dread.

But you have hope. Your cancer can be cured with chemotherapy drugs, and more people are surviving cancer. A report from the American Cancer Society on January 18, 2007, reported cancer deaths have dropped for the second year in a row in 2004, the latest statistics available. That's the first time that has happened in 70 years. Cancer deaths fell by 3014, but there were still 553,888 deaths so these numbers may not mean much for you. But some hope is better than no hope at all. You know more than 50 percent of all cancer victims now survive, and there are more than 10 million cancer survivors out there.

But then you are shocked to find how much cancer drugs cost, to learn that most health plans don’t cover full drug costs of treating your cancer, that the new Medicare Part D bill requires a $4800 co-payment for certain expensive drugs, and that your prognosis remains unpredictable, making planning difficult.

The psychological and emotional impacts of the disease are devastating, and you may turn to prayer and support groups to prop up hope. You learn there is still a long way to go for ultimate answers – biological, psychological, ethical, and economical – and for converting cancer from unmanageable malignancy into a manageable chronic disease.

You will search for the best care medicine can offer and for compassionate doctors. You hope and pray you will beat the odds with the money and support needed to survive.

America’s Top Doctors for Cancer

I sit on the advisory board of a publication America’s Top Doctors for Cancer (A Castle Connolly Guide, New York City, 2005). The publisher and the Board have evaluated and selected 2000 of the nation are leading cancer specialists engaged in preventing, diagnosing, and treating cancers in children and adults.

Friends, relatives, colleagues, and others frequently consult board members about whom we would suggest as the best specialist and the best medical center for a particular cancer. These top doctors, and the latest drug or radiation therapy, may give you your best shot at cure.

Many cancers are potentially curable if caught early. More than 10 million cancer patients have been completely cured (Source; American Cancer Society), and most survivors can cope with their cancer like any other chronic disease. That said, it is important to say no cancer specialists or institution devoted to cancer is perfect. Cancer remains a disease calling for Art, Science, and Hope.

Cancer a Disease of Hope

Perhaps my son, Spencer, who is a nationally known poet because of his book The Clerk’s Tale (Houghton-Mifflin, 2004) ought to be writing this chapter rather than myself.\

Because, when chances for a cure dim, cancer is primarily a disease of hope. You hope against all odds you will survive. Cancer becomes a disease of the soul, mind, and spirit as well as the body. Cancer evokes the language of hope, and poetry lends itself to that language.

Maybe that’s why lists 100 books of poems by cancer victims. Emily Dickinson (1830-1886) penned these lines "Hope is the thing with feathers that perches in the soul,” and John Keats, a medical student at the time, composed the following poem with these opening and closing verses.

To Hope, by John Keats, 1795-1821

When by my solitary hearth I sit,
And hateful thoughts enwrap my soul in gloom;
When no fair dreams before my "mind's eye" flit,
And the bare heath of life presents no bloom;
Sweet Hope, ethereal balm upon me shed,
And wave thy silver pinions o'er my head!

And as, in sparkling majesty, a star
Gilds the bright summit of some gloomy cloud;
Brightening the half veil'd face of heaven afar:
So, when dark thoughts my boding spirit shroud,
Sweet Hope, celestial influence round me shed,
Waving thy silver pinions o'er my head!

The Medical Ethics of Offering Hope to Cancer Victims

For cancer doctors, offering hope, particularly false hope, can be a tricky and cruel ethical exercise.

• Should doctors offer false hope by placing a terminal patient on a ventilator, or should they give morphine or some other powerful pain killer to soothe the passage?

• Should doctors give a precise prognosis, because the law says patients have a right to be realistically informed about their prognosis? Prognosis estimates are based on statistical aggregates, but patients die individually, long before and long after any statistical mean.

• Should doctors passively issue a bleak prognosis, or should they aggressively encourage the patient to pursue unproven cutting edge treatment?

• Should they subject the patient the toxic therapy when, in your heart of hearts and in their experience, they know it will likely fail?

• Should they admit to the patient and family that no doctor knows how long the patient will live – that cancer survival statistics are notoriously imprecise?

• Should and when should they recommend the patient enter a hospice, a tacit admission that the end is near?

Answering any of these questions entails the Art of Medicine, rather than blind belief in the Science of Medicine. Doctors can’t always say precisely when and how things will turn out, but they try can do the best they can and offer emotional support.

When The End Nears

There comes a time when everybody knows – the patient, the family, and the doctor – the end is near. What does the doctor do then?

In Oregon, the patient can consider euthanasia. For most states, hospice is a more realistic option.

I have a friend and colleague, Dr. John Burns, an internist, who has something important to say about terminal care. When confronted by a hopeless situation, Dr. Burns said to patients, “I will always be with you. I will never abandon you, and we will face the end together.” This message, he says, always comforts patients.

Next: Your Doctor and You – With Cancer, With Hope, What You Know and Might Not Know, the Money Problem, Hope Better Than Hopelessnes

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