Walter F Baile, M.D.
Professor, Behavioral Science
The University of Texas M. D. Anderson Cancer Center
Dr. Baile:
In this scenario, a
patient's son, rather abruptly approaches the doctor. There's an old
saying in medicine that if you don't know what to say, take a history.
Here it's a perception check, a very important technique that anyone
can incorporate to good effect for those situations. So the physician's
first words are, "Tell me what you mean by give up." In other words,
he's exploring the perception.
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 the 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.
Dr. Buckman:
Okay.
Son:
Yeah, it doesn't feel like we're doing anything.
Dr. Buckman:
Okay, let me address that. I'll
just quickly summarize the situation. Remember you and I first met like
five years ago when she was first diagnosed.
Son:
Of course, I remember.
Dr. Baile:
And as the son relates his concerns, the physician uses repetition to
acknowledge them. So when the son says, it feels like we're not doing
anything, he asks is that the way it really feels that we're not doing
anything. This acknowledges the person and his perception without
verifying that it's a fact. So these are things we can do in the
presence of emotion. Here what appears to be blame is actually emotion.
Underneath it is anxiety, and fear. The other tried and true technique
here was that when it's time for him to give information to the son,
the physician begins with the narrative. "Let's just sum up where we
are in your mother's treatment." It sets the context. It eases both of
them into the grist of the communication and conversation. It
synchronizes them.
Dr. Buckman:
Okay, let me address that. Then
I'll just quickly summarize the situation. Remember you and I first met
like five years ago when she was first diagnosed.
Son:
Of course, I remember.
Dr. Buckman:
And started the hormone pills after the operation; everything was absolutely fine for just over two 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 two or three months, maybe a little bit longer
then that. Then we started the chemotherapy. We had maybe eight, nine
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 two completely different things. One is, as it were, a
treatment for the breast cancer. The other is treatment looking after
your mother.
Dr. Baile:
The physician is
then able to get to the actual crux of the issue, which is that the
patient's options now are palliative treatment and not curative. And
that it's the son who doesn't want his mother to think that he's given
up on her. Having come to understand this, the doctor is then able to
talk about treating the patient versus treating the cancer, which is a
useful and very supportive perspective to share with patients, and
their families. To help him do that, the physician relied on the
discussion of the biology and the behavior of the cancer to reframe her
care from cure to support.
Now, there's nothing more that we can do about the cancer, but we can concentrate on control of her symptoms. Family members, and others who are close to the patient, sometimes express these kinds of sentiments. You're no doubt aware that they don't always accurately reflect where the patient is. As we saw in this case, she was much more in tune with the medical reality. So often, families' reactions are a reflection of their own fears. In this case, the son actually wanted to know how to handle it himself. I think it would have been a mistake for the physician to have simply said, "There's nothing more we can do." That is to be harshly factual, I think, that would impart a sense of abandonment. And it's important instead to let patients and their families know that we don't abandon them when we abandon curative treatment.
In this scenario, the physician recognized the son's need. He actually praised him for his care, which is also a very effective and therapeutic intervention. And he recognized what I would call anticipatory grief in reassuring the son that he would continue to see him later and that he's not abandoning the patient, or her family.
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