In Defense of Futile Gestures
Authors: Stuart H. Bloom
Journal: Journal of Clinical Oncology (2008)

I had originally met Marni a year and a half earlier on weekend hospital rounds. She was in the middle of her third try of induction chemotherapy for a refractory, poor-risk acute myelogenous leukemia that had developed in the setting of essential thrombocythemia. Still, a few months shy of her 50th birthday, she looked surprisingly fit. She and her husband had a hundred questions regarding her disease, prognosis, and plan for treatment that apparently had not been addressed by her primary oncologist, who was a brilliant diagnostician but not known for his patient communication skills. With her chart in my lap, I sat on the edge of her bed, held her hand, and gently told her what I assumed was old information, that her only chance for cure was to get her disease in remission, then send her for an allogeneic peripheral blood stem-cell transplant. However, she was in the middle of her third try at remission, so the chances of this actually happening were pretty low. Absent remission, we could try a clinical trial of a novel agent, troxacitabine, but this would mean she would have to remain in the hospital for perhaps another month, and again, the chances of success were slim. Focusing on her comfort alone, and not actively treating the leukemia at some point, certainly seemed reasonable. I paused, let this all sink in, and wondered about her response. It was not what I expected. “Would you be my doctor?” she asked. My heart sank. I had just given her extraordinarily bad news. She said all this actually was new information. I doubted that, but maybe after nearly 2 months in the hospital, she was finally ready to begin dealing with everything. And maybe I was the guy to help her do this. Not surprisingly, her primary oncologist had no problem with this arrangement. My new patient failed her third attempt at inducing a remission. A consultation with a tertiary care referral center recommended a fourth attempt (yes, a fourth), which we tried and, of course, that didn’t work. At that point, no longer a candidate for transplant, they recommended supportive care alone. Marni, as she always had, still looked great and really had only minimal complications from all the previous chemotherapy. Though she needed regular transfusions, she was delighted to be out of the hospital, going out to lunch with friends, and hanging out with her children. We talked about troxacitabine, although only one of nine patients who received this treatment with refractory acute myeloid leukemia (AML) had a complete response. We decided to go with supportive care alone, although Marni continued to have some trouble not actively treating her leukemia. She asked me how long she could live with this approach. I told her that the longest I’ve seen in her situation was about 1 year, though we would just take it a day at a time. The aim of therapy here was to maximize her quality of life, as well as help her live as long as possible. She heartily endorsed both of these goals. One month later, still feeling fine, Marni had a change of heart. She just couldn’t live with not doing something to fight her cancer. I felt the chance of any intervention having a meaningful outcome was vanishingly low, and probably futile. Marni was undeterred. Wasn’t there something, anything, we could try as an outpatient?