Oncologists thrive on prolonging life and decreasing human suffering. They have to be optimistic, without providing false hope. They also have to be honest when all treatments fail and clearly communicate a poor prognosis to patients and their families. Most of the time, the patient's overall medical condition and tumor status easily guide decisions to treat or not to treat. But sometimes even the most skilled oncologists find it difficult to predict the future. In these situations, decisions are made through candid discussions with the patient and the caregivers. The patient's final decision to request more therapy or to focus on comfort care is usually based not only on the medical status, but also on social and economic factors. Some patients also take into account the possible burden they may impose on their caregivers.
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The patient was admitted to the hospital with rapidly progressing lymphoma. His lymphoma already relapsed before. As I visited him, I planned to discuss the prognosis and help him decide whether he wanted to try more therapy.
A year earlier, I'd had a similar discussion with the patient and his son. After receiving an aggressive chemotherapy regimen, his lymphoma had grown back. Given his old age, the type of lymphoma and the speed of recurrence, I told the patient that his lymphoma could not be cured. However, given his good overall physical and medical status, I was willing to try one more time. I also told him that he would require close monitoring and frequent visits to the clinic. Without hesitation, the patient quickly requested that we try a new therapy. His son agreed.
The patient lived by himself. During the following months, he came to my clinic every few weeks for check ups and to receive treatment. He also came several times in between, to have blood tests, x-rays, or to manage occasional treatment-related side effects. He always came with a friend. His son accompanied him two or three times and was always in a hurry to go back to work. Yet, the patient never complained. Instead, he always gave unsolicited excuses for his son's absence and always spoke about his son with admiration. "He was in Europe closing on an important business deal." "He was on a college tour with his daughter." "He works so hard; he finally took a vacation with his family and went out of town." Against all odds, the patient's last treatment delayed the progression of his lymphoma for almost a year and allowed him to have a good quality of life. Now, I am in his hospital room, with his son standing next to his bed. We are going to make serious decisions.
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In the final act of Puccini's Tosca, Mario, the main character, sings one of the most beautiful arias in Italian opera, "E lucevan le stelle". It is so beautiful, not only for the wonderful music, but also for the simple lyrics that candidly describe human emotions at dire moments. Facing his imminent death by a firing squad, Mario hopelessly confesses that he never loved life more than that day.
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Like Mario, the patient's eyes were teary as he realized what was coming next. Unlike Mario, he had a choice to make. I presented the advantages and disadvantages of resuming cancer therapy and the expected side effects. Throughout the discussion, he kept looking at his son for guidance. But the son always referred the decision back to his father. "Whatever you wish, Dad." I asked them to discuss these options among each other and to let me know their decision by the next day.
As I walked out of the room, I wondered what the decision would be. Would he be concerned that requesting more therapy would be a burden on his son and his friend? I also wondered whether a different decision would be made if the father were caring for the son.