A patient with advanced lung cancer asked his oncologist about how many years he could expect to live. The doctor replied, “How would you feel about 10 years?” The patient confessed he would be pleased with that prediction even though he had a hunch that it was too optimistic. So, do you think the doctor was misleading this patient with a compassionate purpose in mind? Or, was the patient being led down the path of false hope to avoid engagement in a difficult conversation about prognosis?
These are not simple questions. I suspect you might have expected me to say that being truthful should always be the answer but these are not easy conversations for doctors. I must admit that holding out 10 years as a possibility was overreaching. Instead, what if the patient was asked to identify his goals, what he hoped for? I thought that a key missing piece to this exchange was a discussion about quality of life, not just years in one’s life.
After the meeting with his oncologist I met with this patient and he shared what the doctor said. It was my opportunity to ask what “he” hoped for. He thought for a moment and said, “It may not be realistic but I’d like to go scuba diving in the Caribbean.” His answer had nothing to do with longevity. He emphasized that it was important to set goals and achieve them. I handed my note to the oncologist, which led to them having a candid conversation about realistic goals. The patient lived less than a year and, fortunately, didn’t wait to achieve some of his goals.
The question about what one hopes for inevitably became part of the medical humanist protocol at the Bennington cancer center. The same question was always included in interviews with patients for Center for Communication in Medicine’s educational projects and is a chapter title in SpeakSooner®: A Patient’s Guide to Difficult Conversations.
None of us are prepared to hear bad news but we cannot plan our lives without timely and frank conversations with doctors. What if this patient believed he had 10 years to achieve his goals? So, it’s incumbent on us to take the lead in asking questions about a prognosis, including risks and benefits of treatment options and consideration of quality of life. Keep in mind that some of us should let it be known we prefer to have prognostic information dosed rather than delivered all at once.
Readers of my blog have learned that I often turn to poets and philosophers who have a gift for describing the human experience. When I think about hope, Vaclav Havel’s words come to mind. He said, “Hope is definitely not the same thing as optimism. It is not the conviction that something will turn out well, but the certainty that something makes sense, regardless of how it turns out.”
When it’s all said and done, doesn’t it come down to the “life in one’s years?”