I frequently care for patients with advanced cancer. A majority have tried some combination of surgery, chemotherapy and radiation. Yet, many land back in the hospital because the cancer returned or spread widely. This leaves them in pain that is not easily managed or controlled. Often, they even struggle to breathe.
Often patients decide to stop aggressively fighting their cancer during their hospital stay, and instead focus on palliative care to help achieve a measure of comfort and grace at the end of life. Over the past 20 years, evidence has demonstrated that palliative care decreases pain, improves comfort and even, in some cases, prolongs life a few months.
The moment of transition to accepting palliative care can be subtle. It’s sometimes signaled by a sweet look from a husband to a wife, a gentle touch of the patient’s hand by an adult child, or two simple words: “It’s time.” In my experience, conversations about turning to palliative care often begin with patients recognizing that curing their cancer is no longer an option.
Yes, there is a new generation of cancer treatments that have become available in recent years. The medical literature now gushes with terms like “revolutionary” and “cure.” Many of today’s treatments are deserving of the hype although their cost is staggering –several hundred thousand dollars a year in some cases.
Some new treatments called “immunotherapy” harness the patient’s own immune system to battle a tumor. Others, known as “targeted” therapies, block certain molecules that cancers depend on to grow and spread.
What strikes me most about these new treatments is that they blur the line between cure and comfort, between hope and hopelessness. They have disrupted the fragile equilibrium between hope and easing into the transition of preparing for death.
Patients and family members often hold onto every shred of hope. Even a small chance of cure or prolonged remission will cause the majority to opt for more approaches to deal with their cancer. We already know that despite the unquestioned value of hospice, many patients with end-stage cancer don’t take advantage of Hospice or do so with only a few days left in their life. They needlessly suffered for weeks or even months.
Doctors and nurses need more training in how to have the “hard” conversations with patients in light of the new cancer treatments. They need to be more at ease with the prognostic ambiguity and better versed in the possible benefits and harms of the new therapies so as to give patients an informed choice.
Sadly, for most patients, a cure will prove elusive. As we continue to chase progress in cancer treatment, let’s be sure that we don’t rob dying patients of a smaller, more subtle miracle: a death with dignity and grace, relatively free from pain and discomfort.