Palliative Oncologists: Specialists in the Science and Art of Patient Care
Authors: David Hui, Esmé Finlay, Mary K. Buss, Eric E. Prommer, Eduardo Bruera
Journal: Journal of Clinical Oncology (2015)

DOI: 10.1200/JCO.2014.60.3274 Case Vignette “We’ve been waiting for you to come on the oncology service,” the oncology fellow said, as the resident and nurse practitioner on service looked on. “We have a really challenging case.” Our patient was a frail 77-year-old woman with unresectable pancreatic adenocarcinoma, saddle pulmonary embolus, protein calorie malnutrition, hepatitis C, and recurrent infections, all of which had resulted in a lengthy hospital stay. Her cancer had progressed despite two lines of chemotherapy. She wanted more treatment, but had been told she was too weak. In our first meeting, she told me that her goal was “to get strong enough for more chemotherapy.” She had interpreted the previous oncology attending’s statement about her fitness for chemotherapy as a challenge, and thought, “If I can get stronger, I can get more.” Knowing and trusting my colleague, I imagine his statement was meant as a stepping stone toward a transition to hospice. Her family fiercely defended her desire for rehabilitation as well (“Don’t take away her hope,” they had said), so she remained in a hospital-based limbo, too weak for physical therapy and without sufficient understanding of her prognosis to allow a seamless transition to hospice. As a dual board–certified medical oncologist and palliative care physician, I respected her hopefulness and recognized the challenges that I faced as a result of the complex and nuanced conversations that had occurred before I became involved in her care. I also recognized her profound suffering and that of her family, both because of my conversations with them and because of the heaviness I felt in my heart when entering her room. I suspect that every oncologist knows a version of the above scenario, and knows that heaviness of heart, too. As physicians, we are often most comfortable in the medical and fact-based realms. However, in my palliative care training, I was taught to listen to the so-called limbic music in a room to try to identify the causes of suffering. Often the solution in a difficult clinical encounter lies in addressing emotional and spiritual needs as well as physical ones. Our team aggressively managed the patient’s pain and nausea and then explored her suffering. As a member of a three-generation ranching family, she had been physically active until her diagnosis, and felt betrayed by her body. In the hospital, without her daily dose of open sky, she felt trapped. She did not have a will and worried about who would run the ranch after she passed. Her sons had a contentious relationship and often disagreed about how to care for her. She was overwhelmed and, frankly, not ready to die. She suffered in many realms—physical, emotional, interpersonal, financial and existential— and her suffering affected her decision making. By identifying and addressing the causes of her suffering in the context of our goals-of-care discussions, we helped her to understand that she was not going to regain the physical ability to run the ranch, but that she might be able to see it again, that we could begin to address some of her financial and relationship concerns, and that those things were possible without more chemotherapy. Before her death in the hospital, she had completed a medical power of attorney, had met with her sons and a family lawyer to make a will, and had the opportunity to grieve openly with her sons about her anticipated death. From an educational perspective, an oncology fellow, resident, and nurse practitioner learned to recognize and assess “total pain,” Dame Cicely Saunder’s concept of suffering that encompasses physical, psychological, social, and spiritual domains. This vignette illustrates how palliative oncology experts can influence patient care and education in meaningful ways, and also how palliative care training adds a different dimension to the core skills that all oncologists use.