Commentary on “Unrealistic Expectations”

In her essay, Dr Hartmann artfully captures the essence of one of the more frustrating aspects of medical oncology practice. Interactions with patients and families who harbor deep-seated, unrealistic expectations can not only leave the oncologist physically and mentally drained, but can also lead us to question our ability to manage and comfort patients with advanced, incurable malignancies. As was the case with “Louie,” such patients tend to gravitate to academic centers, where we are always expected to have some new promising therapy to offer, even for the most debilitated patients with faradvanced, refractory disease. Frequently, in such situations, the correct thing to do is to reassure the patient and family that they have received appropriate care and that further anticancer therapy would not be beneficial, while offering additional measures aimed at maximizing comfort and optimizing the delivery of palliative support. The distinction between “expectations” and “hopes” can sometimes be blurred during clinical interactions with our patients. The oncologist’s conversations with Louie’s wife suggest that she may actually have realistic expectations (eg, the discussion of the will and of death), but continues to hold out hope for a miracle (eg, the prayer request). Who can blame her for that? Wouldn’t we all wish for the same thing in her situation? However, problems arise when hopes become expectations. In this situation, focus can subtly shift from taking care of the patient to taking care of the cancer, leading to the overwhelming pursuit of futile and potentially toxic therapy that negatively impacts the quality of life of both patients and their families. When I started my Fellowship, there was a sign on one of the solid tumor wards that read, “Expect Miracles.” Initially, I was vaguely uncomfortable with the message conveyed by the sign, but as I became further and further immersed in the reality of patients with advanced cancer, I grew to absolutely hate it. I felt that it bred unrealistic expectations and false hopes. It can be personally encouraging to hope for miracles, but it is a whole different matter to expect them; we, as oncologists, don’t perform them. Twenty years ago when I began caring for patients with advanced cancer, I sensed a much greater degree of fatalism from them, as well as satisfaction, or at least comfort, with their oncologic care. Only a few seemed to be unrealistic, and it appeared that the primary goal of many patients was to avoid abandonment and suffering. Now, the general tone of patients in our clinics is often very different; many seem to want more than what we can offer and are convinced that something better is out there, somewhere. A major cause of this feeling may be the unreasonable hype generated by the media, the Internet, the drug industry, and many of our academic colleagues about the relatively modest advances that have been made in clinical oncology. Patients and their families are constantly hearing about “breakthroughs” in the war on cancer, and become dissatisfied with the care that they are receiving, especially when their own personal cancer seems to be winning. On the societal level, this is not necessarily a bad thing. It would be foolish to think that the current state of oncologic care is adequate, and, frequently, it is dissatisfaction with the status quo that drives From the Department of Internal Medicine, University of Michigan, Ann Arbor, MI.