This week went by especially quickly; unfortunately it was only a week, as it was a thoroughly stimulating one at hospital on medical oncology. Despite my little-boy-like desire to fiddle with my hands and perform procedures, medical oncology was a very thought-provoking and meaningful experience. In the sense of listening to patients, getting an idea of their issues and concerns, and feeling how they would change through the course of their illness is really fascinating. The humans’ ability to hope; cope with stress, emotions, the pondering of life, reasons behind it and more. I feel, there may be more like this to come with palliative medicine, which I look forward to. Not to see the suffering, but to see the steps taken towards hope and reconciliation with whatever they had to do before the end of life. It’s impressive and really elating.
Indeed, every individual will take a different amount of time, have a different approach to coping with a terminal illness – it appears to be more so if the patient is under the age of 60. Also, new cancer diagnosis after presentation with what appeared to them to be minor symptoms, tend to hit the hardest. We are told the emotional responses include, shock, disbelief, fear, anxiety, guilt, sadness, grief, anger, and more – as described on cancer.org. That is a lot at once. And for me at this stage unimaginable. For grief, there is a Kübler-Ross model (it includes some of the other emotional responses as a part of grief) that comes in five stages: denial, anger, bargaining, depression, and acceptance. It may be a useful tool when it comes down to understanding what patients are going through, but as we already know, each patient is an individual and will expereince things differently, nevertheless these studies are useful for the teaching of how to deal with a certain situation – despite it only being a small degree. There are various other theoretical models, each of which with their own limitations. What can we as clinicians do about them? I suppose a baseline understanding of each of these theories is the start, remembering to take a thorough history from the patient would be important as well, so as to know their individual stance and point of view. When discussing the prognosis with a patient, be PREPARED – in the literal sense of the word and also as an acronym properly put together in a journal article in the MJA.1 P: prepare for the discussion, R: relate to the person, E: elicit patient and caregiver preferences, P: provide information, A: acknowledge emotions and concerns, R: realistic hope (to be fostered), E: encourage questions, D: document. Being prepared goes hand in hand with knowing how to best make the patient feel comfortable, and besides carrying out oneself professionally, discussing what is generally important to most people and tackling what is identified as the main issue for the patient is also very important.2 We often pride ourselves in thinking we know what is best (in every sense of the word), I think it happens far too frequently when doctors overstep their roles as healthcare providers to sometimes forcing their opinions down the throats of their patients (for the lack of a nicer way to put it), I suppose returning to my previous reflection, remembering that human interaction between humans, would be one way to keep things natural and sincerely – hopefully.
To ask a why question about death and dying could take this reflection down a much longer path, that I, myself have not completely explored clearly, and opens a whole other can of worms. I hope will be discussed in coming journals, maybe along with my palliative care week.
Essentially my main reflection on this week was what can we do better as clinicians who work with sick and dying patients… It may be more evident in oncology, but it also cannot be denied that all of us, will eventually die. And death does not have to be something we fear, maybe even something we strive toward (or prepare for). I suppose being open minded and having a big heart would be a start, especially as clinicians, the patients come to us at their most vulnerable, and the immense amount of trust they place in our hands, the very least we can do, is to respect that and acknowledge the deep privilege it is to have that relationship with them; to be with them at that critical point in life. That is just the beginning.
- Clayton JM, Hancock KM, Butow PN, et al. Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a life-limiting illness, and their caregivers. Med J Aust. 2007; 186: S77, S9, S83-108.
- Schofield PE, Butow PN, Thompson JF, Tattersall MHN, Beeney LJ and Dunn SM. Psychological responses of patients receiving a diagnosis of cancer. Annals of Oncology. 2003; 14: 48-56.
“Sarabeth is scared to death… to hear what the doctor will say…”