The Art of Oncology: When the Tumor Is Not the Target—The Power of Silence
Authors: Ruprecht Nitschke, Bruce Himelstein
Journal: Journal of Clinical Oncology (2002)

Article Tools SPECIAL DEPARTMENTS Article Tools OPTIONS & TOOLS Export Citation Track Citation Add To Favorites Rights & Permissions COMPANION ARTICLES No companion articles ARTICLE CITATION DOI: 10.1200/JCO.2002.20.7.1952 Journal of Clinical Oncology - published online before print September 21, 2016 PMID: 11919260 The Art of Oncology: When the Tumor Is Not the Target—The Power of Silence Ruprecht NitschkexRuprecht NitschkeSearch for articles by this author Bruce HimelsteinxBruce HimelsteinSearch for articles by this author Show More University of Oklahoma Health Sciences Center, Oklahoma City, OKPalliative Care Program, Children’s Hospital of Wisconsin, Milwaukee WI https://doi.org/10.1200/JCO.2002.20.7.1952 First Page Full Text PDF Figures and Tables © 2002 by American Society of Clinical OncologyjcoJ Clin OncolJournal of Clinical OncologyJCO0732-183X1527-7755American Society of Clinical OncologyResponse01042002In Reply:I appreciate the opportunity to reply to the thoughtful comments of Dr Nitschke regarding our Art of Oncology article, “The Power of Silence.”1 I cannot agree more that competent and compassionate end-of-life care should include a discussion of the course of dying. As an oncologist and palliative care specialist, I always discuss the course of dying, death, and postmortem care with my patients and families.The true “art” of palliative care, however, is knowing not only what to say but also when to say it and how to say it, given the unique communication styles of individual families and children. In Terry’s case, our experience with her suggested that allowing her time and space to offer questions (“presence and nondoing”), rather than overwhelming her with information, was the best communication strategy. The necessary information was presented to her in a way that was comfortable for her but often uncomfortable for health care providers. It would clearly be improper to recommend this individualized strategy for all. The point of the presentation was to highlight the necessity of good listening skills and the understanding of and respect for communication styles different from our own.As to whether or not to withdraw from the room after presenting treatment options and the process of dying, I also individualize this decision, always asking the preferences of the patient and family. In Terry’s case, she wanted us to stay with her; I apologize that this detail was omitted from the presentation. The ability to be present is an important aspect of the physician-patient relationship that is often overlooked. The importance of the primary physician in pediatric end-of-life care2 may, in fact, suggest an oft-missed opportunity for physicians to be for families “one of the staff members they prefer” to provide support around end-of-life deci-sion making.Finally, the comments regarding Jane’s involvement in decision making are appreciated. Given the point we were trying to raise in our discussion, the details of the many conversations with child and parents, both separately and together, with the help of child psychology and child life staff, were omitted from the case presentation. Jane and Terry, both verbally and nonverbally, had ample opportunity to share their thoughts, feelings, and fears together before Jane’s death.1. Himelstein B, Jackson NL, Pegram L: The power of silence. J Clin Oncol 19:: 3996,,2001 Link, Google Scholar2. Wolfe J, Grier HE, Klar N, et al: Symptoms and suffering at the end of life in children with cancer. N Engl J Med 342:: 326,2000-333, Crossref, Medline, Google Scholar