This Article Full Text (PDF) eLetters: Submit a response to this article Purchase Article View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article link to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Reprints/Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by de Azambuja, E. Search for Related Content PubMed Articles by de Azambuja, E.

End-of-Life Care: The Red Alert for Physicians

Medical Oncology Clinic, Institut Jules Bordet, Brussels, Belgium

"He was my North, my South, my East and West. My working week and my Sunday rest, my noon, my midnight, my talk, my song. I thought that love would last forever; I was wrong..." W.H. Auden.

Experiencing death in daily oncology practice is one of the heaviest aspects of our work, although this moment should be seen as a peaceful task. In 1998, during my first year of oncology training in Porto Alegre, in the South of Brazil, I met Tania (fictitious name), a 56-year-old psychologist who had been referred to our institution by a well-known oncologist in my town to receive adjuvant chemotherapy for her third breast cancer. In 1978, she had had her first breast cancer treated with mastectomy and 2 years of adjuvant chemotherapy. In 1988, she had a contralateral breast cancer treated with surgery alone. In 1998, she had local breast cancer relapse treated with mastectomy, adjuvant chemotherapy, radiotherapy, and endocrine therapy. Unfortunately, she experienced cardiac failure during radiotherapy, which required her to start taking medications and to decrease her physical activity for months.

In 2001, I was already working in my private practice when she had a second local breast cancer relapse and came to see me. We discussed and changed some of her therapies, but these were unsuccessful because some months later she developed lung and bone metastasis. During that visit, she asked if she would be able to attend her daughter’s Ph.D. presentation. I instantaneously said yes because keeping her alive was our main goal (mine and hers). She had been receiving different endocrine therapies and chemotherapy regimens for some months when she developed severe toxicity as a result of chemotherapy, remaining in the hospital for several days, with an important impairment in quality of life. Additionally, progression of disease in the liver was identified.

In mid-2002, during a very long appointment, Tania, her daughter, and I discussed her prognosis and available further treatments. We (her daughter and I) unsuccessfully tried to argue with her about new drugs and future treatments, but she refused them all. She told us, "I do not want to prolong my sick life; I would only accept chemotherapy if I could fully recover." A few days later, Tania came alone to my office, and we had had a difficult conversation about a very interesting and provocative subject: death. It was very interesting mainly because we physicians are used to discussing cure, success, and so on. Most of the time we forget that death is the only near outcome for patients presenting with advanced disease, and it should be properly addressed. She asked me many questions, such as: "How will I die?" "Will I suffer?" "Will it happen suddenly or slowly?" "Will I be in any pain?" At that moment I realized that these simple questions with no "standard answers or guidelines" were so important for her as a patient, as a person, and as a family member. She asked me to take very good care of her and to avoid pain or respiratory failure. Additionally, we agreed that she would not be transferred to an intensive care unit and that no artificial methods to keep her alive would be used.

It was very difficult for me to accept that I was losing one of my oldest patients. Physicians always feel the need to control everything right until the last minute. Oncologists always think about the next chemotherapy regimen or study protocol. We do not like to have our hands tied by the absence of an antitumor drug therapy. We have our own omnipotence, our small world protected by an imaginary unbreakable layer. Many times we forget that medicine is also there to offer our patients a way to relieve anxiety, improve quality of life, and manage pain. We do need to give our patients all the physical and psychological support we can. With current advances in biomedical technologies, physicians might see a "good" death as one involved in the fight against disease [1].

When is the best moment to talk to our patients about end-of-life care? There are some moments in our daily practice with clear indications for introducing this subject. These clinical indications may be either urgent or routine. The urgent indications are imminent risk of death, when a patient talks about wanting to die or inquires about hospice or palliative care, and when a patient was recently hospitalized for severe progressive illness and has severe suffering and a poor prognosis. Routine indications are when discussing prognosis, treatments with a low probability of success, and hopes and fears with a patient, and when a patient has a life expectancy of <6 months [2].

Patients need to know about their clinical conditions and prognoses because their future choices will be based on what they have received as information. They need to be aware about their life expectancies to have time enough to make decisions that might directly or indirectly affect their families’ lives. Furthermore, physicians may address the psychosocial and spiritual needs of their patients. Long-term relationships have become more frequent between oncologists and their patients, which is a consequence of improvements in patient treatment and palliative care. Therefore, this conversation might happen as a routine practice. The last months or weeks may be crucial in decision-making and in changing the lives of many people involved with our patients. For those patients dying of cancer, addressing quality of life is an obligation of their physicians.

How many relationships are broken by a loved one’s death? Most of the time we forget that many husbands have lost their wives and vice versa because of cancer, but they need to continue living; life does not stop for them. What are their feelings, fears, frustrations, and questions about the future? How will they continue living after this very respectfully painful step in life? The patient’s family, not only the patient, deserves all our support as well, but many times we forget them. For patients and families, psychosocial and spiritual issues are as important as physiologic concerns [3].

Dr Quill [2] has written an excellent conclusion to his article: "Helping patients achieving as good and meaningful a death as possible is part of what we do as physicians. When physicians provide their patients with honesty, expertise, advocacy, compassion, and commitment they would want for themselves and their families, they provide the highest quality of medical care possible." The natural history of cancer has been characterized as a "living dying" experience in which the patient and the family attempt to maintain control and "normalize" everyday activities in the face of impending loss [4].

It has been almost 2 years since Tania’s death, and I remember her every time that I need to discuss prognosis with my patients. I always remember her as a strong person fighting for life and for quality of life without measuring any efforts, mainly because her last and most important fight was a peaceful death.

DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST

The author indicates no potential conflicts of interest.

ACKNOWLEDGMENT

I am thankful to the patient’s daughter for all her support and approval of this manuscript in tribute to her mother.

REFERENCES

1. Steinhauser KE, Christakis NA, Clipp EC et al. Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA 2000;284:2476–2482.[Abstract/Free Full Text]
2. Quill TE. Perspectives on care at the close of life. Initiating end-of-life discussions with seriously ill patients: addressing the "elephant in the room." JAMA 2000;284:2502–2507.[Abstract/Free Full Text]
3. Steinhauser KE, Clipp EC, McNeilly M et al. In search of a good death: observations of patients, families, and providers. Ann Intern Med 2000;132:825–832.[Abstract/Free Full Text]
4. Muzzin LJ, Anderson NJ, Figueredo AT et al. The experience of cancer. Soc Sci Med 1994;38:1201–1208.[CrossRef][Medline]

This Article Full Text (PDF) eLetters: Submit a response to this article Purchase Article View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article link to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Reprints/Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by de Azambuja, E. Search for Related Content PubMed Articles by de Azambuja, E.