Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

For each cancer patient, there is one perfect path

James C. Salwitz, MD
Physician
December 16, 2015
Share
Tweet
Share

There is only one correct, perfect, absolute approach to life and decisions near its end.   This truth relieves the doctor of final decision.   The right way lifts the burden of anxiety, confrontation or guilt.   The perfect path makes giving care at a very hard time, much easier. That correct course, the only way to treat every patient and every family, is exactly what the patient and family say it is.

This idea is simplistic, even contrite. Each end-of-life journey, for every patient and family, is full of stop and go’s, bumps and bruises, highs and lows. How can this be perfect? Because, we die as we live, with stops, bumps, highs, and lows. The doctor, patient, and family must understand that this is the human experience. We will come to the end of our journey by the road most natural for us and us alone. There is no right or wrong; there is the panorama of our lives.

The problem with this philosophy of care, which only requires informing each patient and family of choice and then supporting their decisions, is that it can produce what seems like unnecessary suffering. Often patients and families pick alternatives that almost deliberately result in pain, fear and loss. Doctors who have walked the path many times, see the horror around the bend.   Therefore, supporting choices that are bound to increase suffering, feels futile, uncaring and desperate.

I recently saw three patients that illustrate such disparate experience. The diseases are similar, the final result will be the same, the paths chosen different.

They are less than 50 years old: a wife, a sister, a husband. They have advanced stomach cancer, metastatic colon cancer and spreading pancreatic cancer. They have undergone extensive treatment: surgery, radiation, and chemo. All have increasing, resistant disease, unlikely to respond to treatment. Wheelchair or bed bound, severely wasted with sunken, frightened eyes, they will die in the next few months. Each is in pain.

With their families, these patients have chosen their paths. The first has decided to build up, get stronger, so that she may begin new “aggressive” chemotherapy and fight the disease. Despite being told that the likelihood of benefit from chemo is slight, they plan to continue the battle. They demand IV hydration and nutrition, minimal pain control, physical therapy, transfusions, frequent lab tests and they intend to begin anti-cancer drugs, as soon as she is ready. She is full code: Her doctors have been told to put her on machines, if her heart or lungs stop.

The second, is receiving off-label chemotherapy, which is unlikely to help and which is causing debilitating side effects, including precious days in hospitals or doctor offices. They do not plan to put her on a respirator if she stops breathing, but would use drugs to stimulate her heart or dialysis to support her kidneys.

The last patient and family, making decisions at a nearly identical life moment, has decided to focus on “aggressive” pain control. They will give intravenous hydration only if thirst becomes a significant symptom. They are moving into palliation and hospice. They do not want extraordinary measures of life support such as CPR, ventilator machines, artificial feeding or dialysis.

For the physician, knowing that two of these paths may result in preventable suffering, supporting these choices is not easy. Nonetheless, the patient and family must decide on the steps of the journey. Only they can put into these hard decisions in the context of their lives. Therefore, each of these plans is perfect, and it is my job to design, administer and support. The real question is whether such suffering is necessary?

Life is complex and at no point do we make universally ideal decisions. Every moment is a compromise. From the moment of birth, we make infinite choices between alternative paths. Only each person can understand the consequences; gain and loss, success and failure, joy and guilt. This mélange of dreams and loss comes to its final test in a brilliant naked moment as the universe screams “this is it.”

It is within this personal zeitgeist that every patient and family, must make the hardest of decisions. This is not a context we can easily articulate or explain; it is the base and substance of who we are. We make decisions, many painful, built on the foundation of our lives. It is right for us, even if it would be deeply wrong for a friend, neighbor or doctor.

The physician will never completely understand the patient. That is not her calling. The job is to explain disease, treatment, and the likely, possible, outcome. The doctor may recommend, based on the wisdom of a career; predict what is coming round the bend. However, the clinician’s burden is to understand that for each patient and family there is one perfect path, and to support them on that journey.

James C. Salwitz is an oncologist who blogs at Sunrise Rounds.

ADVERTISEMENT

Image credit: Shutterstock.com

Prev

7 things doctors should consider before signing for a new job

December 16, 2015 Kevin 6
…
Next

Hospitals and doctors should better prepare for winter. Here's how.

December 16, 2015 Kevin 0
…

Tagged as: Oncology/Hematology

Post navigation

< Previous Post
7 things doctors should consider before signing for a new job
Next Post >
Hospitals and doctors should better prepare for winter. Here's how.

ADVERTISEMENT

More by James C. Salwitz, MD

  • Each line on the radiology list is a patient’s line in the sand

    James C. Salwitz, MD
  • The broader mission for hospice care

    James C. Salwitz, MD
  • Is the medical profession at its end?

    James C. Salwitz, MD

Related Posts

  • Healing and heart when recovering from cancer

    Pat Wetzel and Sherry-Ann Brown, MD, PhD
  • A letter to a cancer patient in palliative care

    Alison Vasa
  • Happy National Grateful Patient Day!

    R. Lynn Barnett
  • My first patient to be diagnosed with cancer

    Ton La, Jr., MD, JD
  • A silent moment with a dying patient

    Ramses Perez
  • Including the patient perspective on tumor boards

    Don S. Dizon, MD

More in Physician

  • How policy and stigma block addiction treatment

    Mariana Ndrio, MD
  • Why don’t women in medicine support each other?

    Jessie Mahoney, MD
  • IMGs are the future of U.S. primary care

    Adam Brandon Bondoc, MD
  • The high cost of gender inequity in medicine

    Kolleen Dougherty, MD
  • Women physicians: How can they survive and thrive in academic medicine?

    Elina Maymind, MD
  • How transplant recipients can pay it forward through organ donation

    Deepak Gupta, MD
  • Most Popular

  • Past Week

    • Why your clinic waiting room may affect patient outcomes

      Ziya Altug, PT, DPT and Shirish Sachdeva, PT, DPT | Conditions
    • The human case for preserving the nipple after mastectomy

      Thomas Amburn, MD | Conditions
    • Nuclear verdicts and rising costs: How inflation is reshaping medical malpractice claims

      Robert E. White, Jr. & The Doctors Company | Policy
    • How new loan caps could destroy diversity in medical education

      Caleb Andrus-Gazyeva | Policy
    • The ethical crossroads of medicine and legislation

      M. Bennet Broner, PhD | Conditions
    • How community and buses saved my retirement

      Raymond Abbott | Conditions
  • Past 6 Months

    • Health equity in Inland Southern California requires urgent action

      Vishruth Nagam | Policy
    • Why transgender health care needs urgent reform and inclusive practices

      Angela Rodriguez, MD | Conditions
    • How restrictive opioid policies worsen the crisis

      Kayvan Haddadan, MD | Physician
    • Why primary care needs better dermatology training

      Alex Siauw | Conditions
    • New student loan caps could shut low-income students out of medicine

      Tom Phan, MD | Physician
    • Why pain doctors face unfair scrutiny and harsh penalties in California

      Kayvan Haddadan, MD | Physician
  • Recent Posts

    • Coconut oil’s role in Alzheimer’s and depression

      Marc Arginteanu, MD | Conditions
    • How policy and stigma block addiction treatment

      Mariana Ndrio, MD | Physician
    • Unused IV catheters cost U.S. hospitals billions

      Piyush Pillarisetti | Policy
    • Why U.S. universities should adopt a standard pre-med major [PODCAST]

      The Podcast by KevinMD | Podcast
    • Ancient health secrets for modern life

      Larry Kaskel, MD | Conditions
    • How the internet broke the doctor-parent trust

      Wendy L. Hunter, MD | Conditions

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Why your clinic waiting room may affect patient outcomes

      Ziya Altug, PT, DPT and Shirish Sachdeva, PT, DPT | Conditions
    • The human case for preserving the nipple after mastectomy

      Thomas Amburn, MD | Conditions
    • Nuclear verdicts and rising costs: How inflation is reshaping medical malpractice claims

      Robert E. White, Jr. & The Doctors Company | Policy
    • How new loan caps could destroy diversity in medical education

      Caleb Andrus-Gazyeva | Policy
    • The ethical crossroads of medicine and legislation

      M. Bennet Broner, PhD | Conditions
    • How community and buses saved my retirement

      Raymond Abbott | Conditions
  • Past 6 Months

    • Health equity in Inland Southern California requires urgent action

      Vishruth Nagam | Policy
    • Why transgender health care needs urgent reform and inclusive practices

      Angela Rodriguez, MD | Conditions
    • How restrictive opioid policies worsen the crisis

      Kayvan Haddadan, MD | Physician
    • Why primary care needs better dermatology training

      Alex Siauw | Conditions
    • New student loan caps could shut low-income students out of medicine

      Tom Phan, MD | Physician
    • Why pain doctors face unfair scrutiny and harsh penalties in California

      Kayvan Haddadan, MD | Physician
  • Recent Posts

    • Coconut oil’s role in Alzheimer’s and depression

      Marc Arginteanu, MD | Conditions
    • How policy and stigma block addiction treatment

      Mariana Ndrio, MD | Physician
    • Unused IV catheters cost U.S. hospitals billions

      Piyush Pillarisetti | Policy
    • Why U.S. universities should adopt a standard pre-med major [PODCAST]

      The Podcast by KevinMD | Podcast
    • Ancient health secrets for modern life

      Larry Kaskel, MD | Conditions
    • How the internet broke the doctor-parent trust

      Wendy L. Hunter, MD | Conditions

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...