Robert A. Buckman, M.D., Ph.D.
Adjunct Professor, Behavioral Science
The University of Texas M. D. Anderson Cancer Center
Son:
Look, whatever she tells you you're not to give up on my mother.
Dr. Buckman:
Tell me what you mean by "give up."
Son:
Well, it feels like we're not doing
anything, like we should be doing more chemotherapy or medicine or
something. I don't know, but something can help her.
Dr. Buckman:
Yeah, but how does it look to you at the moment? You tell me how you see this situation with your mother right now.
Son:
Well, she's sick and we're not doing anything to make her better.
Dr. Buckman:
Is that the way it feels, that we're not doing anything?
Son:
That's what it feels like. Yeah, it doesn't feel like we're doing anything.
Dr. Buckman:
Okay, let me address that. I'll
just quickly summarize the situation. I mean remember you and I first
met like 5 years ago when she was...
Son:
Of course I remember.
Dr. Buckman:
...first diagnosed. We started the hormone pills after the operation. Everything was absolutely fine for just over 2 years.
Son:
Yeah.
Dr. Buckman:
And then we tried the second
hormone pills. They worked for a time. The third hormone pills actually
only worked for 2 or 3 months: maybe a little bit longer than that.
Then we started the chemotherapy. We had maybe 8-9 months of response
to the first chemotherapy approximately, a short response to the
second, and nothing to the third and nothing to this one.
Son:
Yeah. Well so what's next? I mean we did hormones, we did chemotherapy. What do we do next?
Dr. Buckman:
Well, I'll answer what's next.
There are 2 completely different things. One is as it were treatment
for the breast cancer. The other is treatment looking after your mother.
Son:
Well aren't those the same thing?
Dr. Buckman:
Not necessarily.
Son:
I mean we want to make my mother better.
Dr. Buckman:
We'd like to make...
Son:
We don't want to give up on her.
Dr. Buckman:
Well, up to now what we've been
trying to do is to make your mother better by controlling the cancer
and keeping the cancer back. At this moment, we've run out of treatment
options for the cancer. There's nothing that we can do - that we can
give your mother now - that will make the cancer go back in towards
remission.
Son:
Isn't there anything new? Anything
experimental? Stuff just out? I mean stuff has worked for her. I mean a
lot of this stuff has worked well. There must be something else that
she's going to respond to.
Dr. Buckman:
I'm sorry to tell you this Mark, but this is unfortunately this is the
way breast cancer behaves. It's nothing to do with your mom or us or
anything else and not with new treatments or anything. Ultimately in
every situation with breast cancer that's spread to distant sites:
metastasized ultimately, the breast cancer becomes resistant to the
therapy and this is the situation we're in. Now we can do a lot to look
after your mother in terms of symptoms. In fact, through the way I've
changed her pain control at the moment the pain is under pretty good
control. She has virtually no pain at all. In fact I'm really hoping -
as I was saying - that we'll probably be able to get her out of the
hospital in 2 or 3 days. But I can't do anything to actually make the
breast cancer go back. I can only look after your mother and her
symptoms.
Son:
I just don't want us to give up on her. If she feels we're giving up, then she's going to give up.
Dr. Buckman:
I hear what you're saying about
giving up. Let me tell you something. I've never talked to your mother
without you being there. I said I wouldn't and I haven't. But one of
the nurses on night duty speaks a bit of Gudgerati and she passed on
the message that your mother - just recently - has got to the stage
where she's basically wanting to stop the chemotherapy treatment.
Son:
When was this?
Dr. Buckman:
Well it was a couple of days ago, but that's obviously quite a shock. But that's the situation your mother might be...
Son:
I didn't think she wanted to give up.
Dr. Buckman:
No. That obviously comes as a bit of a shock and a bit of something that overwhelms you a little bit?
Son:
Yeah.
Dr. Buckman:
Mark, sometimes the patient sees things differently from family
members. Sometimes it happens that the patient, for example, wants to
go on with treatment and the families say "No please stop." Sometimes
it's the other way around. Sometimes the patient sort of knows or
senses that the treatment isn't working and just wants to stop the
treatment. And because the family doesn't have the same feelings about
the disease - they can't sense the disease in quite the same way - they
may be still feeling we should try. The important thing is if your
mother wants to stop the treatment against the cancer - which isn't
working - she will not be abandoned by you or by me. We need to make
her know that too. Is that making sense to you?
Son:
Yeah.
Dr. Buckman:
What I'd like you to do, is when we go and see her this afternoon I'd
like you to translate this one simple question to her. ":How do you
feel about the chemotherapy?" And if she says "I've had enough of it,"
I'd like you to tell me that. If she says something else, I'd like you
to translate that to me honestly. But we need to tell her that we will
continue the treatment of her, looking after her, her symptoms, and how
she is no matter what.
Son:
How do I ask her that without making her feel that I'm giving up and that you're giving up?
Dr. Buckman:
Because she will know absolutely
that you are not giving up on her. That's a fear, obviously, that you
have that somehow you'll be letting her down. That's not the case.
That's not the way it is. You've been there, basically, every day that
she's been in the hospital. You're there all the time. There's no
possibility of you giving up on her. The fact that we have got to a
stage where the breast cancer is resistant to the chemotherapy is not
the same thing at all. It feels to me is that this is very hard on you.
Son:
Yeah.
Dr. Buckman:
It's tough. Mark, I say this to
quite a lot of relatives and this is an open offer. It may be very hard
afterwards. If it is, you can come and see me and we can talk
afterward. I do that with quite a few relatives afterwards. They come
and see me. Maybe there are questions that they didn't understand at
the time. Maybe they're just things they want to get off their chest,
things that, feelings that they've had. I'm making that offer to you.
If you would like to, please do come and see me afterwards as well.
Son:
Okay.
Dr. Buckman:
Any other questions you wanted to ask about your mom?
Son:
So what will we do for her?
Dr. Buckman:
Control all of the symptoms as best
we can. So we shift the objective from trying to keep the cancer back -
which we can no longer do - to controlling the symptoms, which we have
a very high chance of success. When we have pain, basically on the new
medication I've just changed, basically her pain is under very good
control. She has very little pain. In fact as I said to you, we'll
probably be able to get her out of the hospital in 2 or 3 days. If she
develops other symptoms, nausea, pain in other places or whatever, even
loss of appetite to some extent we might be able to ginger that up a
little bit with some treatment. We can address each symptom as it
arises. That's all we can do and it's all we should do. We don't want
to make her more ill. And we do want to control all of symptoms that we
can to the best of our ability.
Son:
How long?
Dr. Buckman:
Do you mean how long has she got? That's a very difficult question.
Would you like me to sort of try an answer to it? Your mother's breast
cancer has never been one of the fast moving ones. It's not one of the
slowest certainly, but it's not one of the very fast moving ones. It's
often like this in a person of your mother's age group. From this
moment, we're probably talking about a small number of months of life.
Not a large number of months but certainly not you know 4 weeks or
something like that. We're probably talking about a small number of
months. Was that a shock to you? I guess that's what you've been
expecting.
Son:
I guess.
Dr. Buckman:
But the important thing is to keep
the quality of her living as high as we possibly can during that time.
And that means a constant watch over the symptoms. I want you to tell
me if her symptoms are getting worse and we'll try to keep them under
control.
Son:
Okay.
Dr. Buckman:
Alright [inaudible], let's go and see her.
Son:
Okay. Thanks.
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