- Email: [email protected]
Social radiation oncology
Practical Radiation Oncology (2015) 5, 328-329
www.practicalradonc.org
Narrative Oncology
Social radiation oncology A. Robert Kagan MD, Kelly E. Goldman MD ⁎ Department of Radiation Oncology, Kaiser Permanente, Los Angeles, California Received 31 January 2015; revised 5 February 2015; accepted 10 February 2015
DJ’s cancer has recurred. His stage IV lung cancer showed a promising initial response to multiagent chemotherapy, radiation therapy to a residual mediastinal mass, and stereotactic radiosurgery to 3 cerebral deposits. Now, along with a 20% weight loss, his cancer has recurred in the brain and mediastinum and he has new lesions in the liver and lung. He ambulates with difficulty because of weakness and dyspnea and will soon need assistance for his physical needs. Your recommendation for next steps in management of his case includes the following. 1. Refer to hospice. No antineoplastic treatment will be helpful. 2. Explain the risks and benefits of reirradiation of the brain for hemiparesis and mediastinum for dyspnea. Patients, whether they ask not, always want to know if they can be cured. Will he suffer? Will the radiation work? Whether asked or not, one should anticipate and respond to these questions. 3. Review his diagnosis and prognosis with words and body language that reflect compassion and sympathy. 4. Ask the patient about his needs and wishes. What does he expect from further treatment? There is no “right answer” to this multiple choice test. Problems that have no “correct” solution are often the most difficult to solve. What can we do to help our patient, DJ? Treatment decisions for the incurable patient often boil down to a negotiation between doctor and patient, influenced perhaps by factors ranging from the patient’s Conflicts of interest: None. ⁎ Corresponding author. Department of Radiation Oncology, Kaiser Permanente, 4950 Sunset Blvd, 2nd Floor, Los Angeles, CA 90049. E-mail address: [email protected] (K.E. Goldman).
own personal or cultural experiences to exposure to successful marketing ploys. As with DJ, many patients are led to believe that the “send off” from the referring doctor to the radiation oncologist will fix things and make them better. This may also result in a perception that overestimates the ultimate good that additional treatment can bring during the last weeks of life. Although we often deny it, radiation oncologists continue to have difficulty explaining to a patient why home hospice or palliative care may be better than further antineoplastic treatment. Asking patients about their own goals and treatment wishes may reveal discrepancies between the physician’s views on oncologic management and those of the patient. There is no universal management algorithm for the incurable patient. Each patient is unique and different. Medical education’s emphasis on technology and automation tends to relegate the teaching of social skills to the lowest level of training, often to the point of it being completely ignored. The value we assign to the ability of physicians to make patients feel comfortable by ameliorating fears and anxieties, showing compassion, and being empathetic (often called a good bedside manner) has diminished significantly. One method we have used to improve our own patient communication is talking to a mirror as if the mirror is the patient. Many physicians are surprised by how wooden their demeanor can be and are oblivious to the impact of their own facial expressions. Over the years, we have found doctors often deliver “bad news” or discuss a patient’s poor prognosis with a facial expression resembling a smiling wolf with indigestion. Even with the best intentions and most thought-out prose, physicians cannot engender trust if their facial expressions make the patient uncomfortable. Another method to improve communication is to record oneself. Listening to the result may reveal a vocal tone lacking compassion or an attitude of moral superiority. One may discover the
http://dx.doi.org/10.1016/j.prro.2015.02.005 1879-8500/© 2015 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.
Practical Radiation Oncology: September-October 2015
alarming traits of stubbornness and inability to listen, which are common in oncologists. Throughout our residency training, we each sought out mentors who demonstrated the communication skills we were lacking and continually observed and emulated these physicians. In our experience, some of the more serious mistakes physicians make in counseling patients are: ▪ ▪ ▪ ▪
Not checking what the patient knows Not allowing for moments of quiet Using medical terminology without explanation Giving rapid-fire information, especially regarding treatment side effects ▪ Underestimating what is happening emotionally to the patient ▪ Skipping over mild symptoms. Many patients choose to depend upon family members to make final treatment decisions, preferring not to make choices themselves. Fortunately, a strong family member can often guide the patient in decision-making. If not, negotiation for a shared treatment option may be layered with different opinions. Arriving at a uniform informed consent may, in this instance, be unlikely. In such a tenuous situation, the help of a social worker can be invaluable. Additional examples in which we routinely try to involve a social worker are cases in which English is a second language, cases where we worry about sensitivity to cultural values, and situations where patients suffer from impaired cognitive function.
Social radiation oncology
329
What was the outcome in DJ’s case? During the initial consultation with DJ and his family members, you guided them through a comprehensive discussion regarding his diagnosis, poor prognosis, and limited value of additional treatment. As anticipated, DJ asked difficult questions and you provided him with candid answers. They requested additional time at home to consider the options. DJ later called you requesting to proceed with additional radiation therapy—enrolling in hospice was perceived by his three children as “giving up.” Unfortunately, after 3 fractions of palliative treatment to his mediastinal mass, DJ developed worsening dyspnea and fevers. He was soon admitted to the intensive care unit with pneumonia and sepsis. You visited him in the intensive care unit, and after a brief discussion, DJ decided to discontinue further radiation therapy. He is placed on comfort measures and discharged home with hospice care. Having laid the foundation with DJ and his family during your initial consultation, a sense of ease was instilled into DJ’s final decision regarding his care during the hospitalization. Your approach to the initial encounter with him led to a keen recognition that he was not yet prepared for this decision. Ultimately, your patience and respect for the patient’s interest served as his guide. Thus, the primary roadblock to effective and successful communication is that doctors often prioritize their authority over interest in the patient’s needs. Unfortunately, the best way to discover the truth of that message may be to become a patient yourself.
www.practicalradonc.org
Narrative Oncology
Social radiation oncology A. Robert Kagan MD, Kelly E. Goldman MD ⁎ Department of Radiation Oncology, Kaiser Permanente, Los Angeles, California Received 31 January 2015; revised 5 February 2015; accepted 10 February 2015
DJ’s cancer has recurred. His stage IV lung cancer showed a promising initial response to multiagent chemotherapy, radiation therapy to a residual mediastinal mass, and stereotactic radiosurgery to 3 cerebral deposits. Now, along with a 20% weight loss, his cancer has recurred in the brain and mediastinum and he has new lesions in the liver and lung. He ambulates with difficulty because of weakness and dyspnea and will soon need assistance for his physical needs. Your recommendation for next steps in management of his case includes the following. 1. Refer to hospice. No antineoplastic treatment will be helpful. 2. Explain the risks and benefits of reirradiation of the brain for hemiparesis and mediastinum for dyspnea. Patients, whether they ask not, always want to know if they can be cured. Will he suffer? Will the radiation work? Whether asked or not, one should anticipate and respond to these questions. 3. Review his diagnosis and prognosis with words and body language that reflect compassion and sympathy. 4. Ask the patient about his needs and wishes. What does he expect from further treatment? There is no “right answer” to this multiple choice test. Problems that have no “correct” solution are often the most difficult to solve. What can we do to help our patient, DJ? Treatment decisions for the incurable patient often boil down to a negotiation between doctor and patient, influenced perhaps by factors ranging from the patient’s Conflicts of interest: None. ⁎ Corresponding author. Department of Radiation Oncology, Kaiser Permanente, 4950 Sunset Blvd, 2nd Floor, Los Angeles, CA 90049. E-mail address: [email protected] (K.E. Goldman).
own personal or cultural experiences to exposure to successful marketing ploys. As with DJ, many patients are led to believe that the “send off” from the referring doctor to the radiation oncologist will fix things and make them better. This may also result in a perception that overestimates the ultimate good that additional treatment can bring during the last weeks of life. Although we often deny it, radiation oncologists continue to have difficulty explaining to a patient why home hospice or palliative care may be better than further antineoplastic treatment. Asking patients about their own goals and treatment wishes may reveal discrepancies between the physician’s views on oncologic management and those of the patient. There is no universal management algorithm for the incurable patient. Each patient is unique and different. Medical education’s emphasis on technology and automation tends to relegate the teaching of social skills to the lowest level of training, often to the point of it being completely ignored. The value we assign to the ability of physicians to make patients feel comfortable by ameliorating fears and anxieties, showing compassion, and being empathetic (often called a good bedside manner) has diminished significantly. One method we have used to improve our own patient communication is talking to a mirror as if the mirror is the patient. Many physicians are surprised by how wooden their demeanor can be and are oblivious to the impact of their own facial expressions. Over the years, we have found doctors often deliver “bad news” or discuss a patient’s poor prognosis with a facial expression resembling a smiling wolf with indigestion. Even with the best intentions and most thought-out prose, physicians cannot engender trust if their facial expressions make the patient uncomfortable. Another method to improve communication is to record oneself. Listening to the result may reveal a vocal tone lacking compassion or an attitude of moral superiority. One may discover the
http://dx.doi.org/10.1016/j.prro.2015.02.005 1879-8500/© 2015 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.
Practical Radiation Oncology: September-October 2015
alarming traits of stubbornness and inability to listen, which are common in oncologists. Throughout our residency training, we each sought out mentors who demonstrated the communication skills we were lacking and continually observed and emulated these physicians. In our experience, some of the more serious mistakes physicians make in counseling patients are: ▪ ▪ ▪ ▪
Not checking what the patient knows Not allowing for moments of quiet Using medical terminology without explanation Giving rapid-fire information, especially regarding treatment side effects ▪ Underestimating what is happening emotionally to the patient ▪ Skipping over mild symptoms. Many patients choose to depend upon family members to make final treatment decisions, preferring not to make choices themselves. Fortunately, a strong family member can often guide the patient in decision-making. If not, negotiation for a shared treatment option may be layered with different opinions. Arriving at a uniform informed consent may, in this instance, be unlikely. In such a tenuous situation, the help of a social worker can be invaluable. Additional examples in which we routinely try to involve a social worker are cases in which English is a second language, cases where we worry about sensitivity to cultural values, and situations where patients suffer from impaired cognitive function.
Social radiation oncology
329
What was the outcome in DJ’s case? During the initial consultation with DJ and his family members, you guided them through a comprehensive discussion regarding his diagnosis, poor prognosis, and limited value of additional treatment. As anticipated, DJ asked difficult questions and you provided him with candid answers. They requested additional time at home to consider the options. DJ later called you requesting to proceed with additional radiation therapy—enrolling in hospice was perceived by his three children as “giving up.” Unfortunately, after 3 fractions of palliative treatment to his mediastinal mass, DJ developed worsening dyspnea and fevers. He was soon admitted to the intensive care unit with pneumonia and sepsis. You visited him in the intensive care unit, and after a brief discussion, DJ decided to discontinue further radiation therapy. He is placed on comfort measures and discharged home with hospice care. Having laid the foundation with DJ and his family during your initial consultation, a sense of ease was instilled into DJ’s final decision regarding his care during the hospitalization. Your approach to the initial encounter with him led to a keen recognition that he was not yet prepared for this decision. Ultimately, your patience and respect for the patient’s interest served as his guide. Thus, the primary roadblock to effective and successful communication is that doctors often prioritize their authority over interest in the patient’s needs. Unfortunately, the best way to discover the truth of that message may be to become a patient yourself.