“Can we fit just a few more?” This was the question I was asked one snowy evening. Pretty soon, I found myself surrounded by no less than 20 people. They had all convened here to see the man lying in bed at the center of the room. He had struggled with cancer, which had progressed through numerous treatments, leading to his current intubated and sedated state. As an internal medicine resident, my role here was as a leader of the “goals of care” discussion. I had only uttered a few sentences before the patient’s wife interjected, exclaiming that we simply could not withdraw care. It was too soon, and this would be giving up. The patient had stated that he would fight to the end; he would never let the cancer win.
The harmful language of fighting cancer
In my brief career in medicine, I find it remarkable just how common the language of fighting is, especially as it relates to cancer care. The disease does not just become an unfortunate affliction, but rather, it grows to represent an enemy that must be conquered and a battle that must be won. The fight against this foe must be valiant even, and perhaps especially, if the chances of victory are bleak. Subtly implicit in this is a potential character judgment, the idea that somehow in choosing not to continue through the treatments, the procedures, the surgeries, that one gave up. If a poor outcome occurs, the family is potentially left with the devastation that the effort put in was simply not enough.
However, choosing to not pursue treatment, or to halt it, should never be considered in this way. Research shows that, at times, the decision to forego treatments for supportive care can even lead to longer lives with better reported quality of life. Furthermore, some treatments are associated with an enormous time burden for patients and families, requiring frequent hospital visits, clinic appointments, imaging studies, and much more. Thus, at times, the “time toxicity” associated with aggressive therapy can be as detrimental as the actual therapy itself to a patient’s quality of life. Therefore, we must take care to radically reframe the way we address cancer care and our role as physicians in it.
Reframing the goals of oncologic care
By reframing how we talk about cancer care with our patients, we can make a statement in support of compassionate and empathetic care. This is where possibilities such as palliative care and hospice can help patients and their families find acceptance and the best path forward. Good oncologic care is not just about shrinking the tumor or turning the circulating tumor DNA (ctDNA) testing negative. Rather, it is about managing uncertainty, relieving symptoms, meeting patients where they are, and walking with them through the uncertain road that is living a life with, and even after, cancer.
In this case, after a brief discussion with the family, we mutually decided to wake the patient so that he could participate in the discussion. Frail from therapy, when asked, he nodded to indicate that he wanted to be made comfortable and did not want any further treatment pursued. Thus, the breathing tube was removed, and in what was one of the most moving displays I have seen in my young career, he was draped in his traditional garments and passed away shortly thereafter surrounded by loving and mourning family members.
This patient was brave. He did not lose a battle. He chose how to live, and ultimately, when to stop further intervention. Supporting that choice is not a failure of care, it is the essence of good medicine. Patients allow us the honor of guiding them through the most difficult decisions of their lives in an unbiased and humane way. Our language as physicians should be worthy of it.
Zachary Scharf is an internal medicine resident.
