Reading the comments on the post about how hospice could have started earlier than it did for Uzma and why that was important, I find myself thinking more about our experience.

Why Patients Don’t Bring It Up

The first question that pops in my head is, how come both of us — Uzma and I —  being physicians, we didn’t think of hospice earlier? Why should it only be the oncologists’ responsibility? We were physicians. We have many physician friends, even friends who are oncologists. Uzma had acceptance of her mortality. She had pushed through to get a palliative care physician. Yet, we didn’t see it then, as I see it today. There are two reasons why bringing up hospice has to be the oncologists’ responsibility.

First, even the most unflinching-from-death patient has ambivalence about it. There are many unfinished projects. For Uzma, our young kids were an unfinished project like no other that contributed to us being in two minds. At one point in September, she said mournfully, “I have become completely worthless. I am only a burden now. I should just die.” How does a caring husband respond to this? I said, “I couldn’t disagree more. Your mere presence in this home is a blessing for the kids. See how the first thing they wanna do every day when they return from school is to sit with you?”

I look back at that interaction and realize how it could create pressure for a patient to keep going on. But I don’t think any family, while caught up in the struggle of terminal cancer, can avoid responding in some version of what I said. No family member is going to say at that moment, “You are right, you are just a burden. Let’s talk hospice!” The struggle between acceptance and denial played out in our minds every single waking moment of our lives since Uzma’s stage 4 diagnosis. Sometimes even our dreams were taken over by that struggle. It’s also not the responsibility of friends — even the friends who are oncologists — to bring up hospice in that circumstance. They were our friends, not our doctors. Their primary role is to support us, not to lay out treatment and end-of-treatment options.

The second reason has to do with the difference between what oncologists know and what patients and families don’t know. Based on my experience in my specialty, I suspect that seasoned oncologists know when a stage 4 cancer patient’s illness and treatment has reached a phase where the odds of recovery/remission with the next best option are too low. Patients and their families don’t have the same information. The oncologists also know — or should know — everything that hospice means.  I am a physician, and I knew hospice as comfort care, not a death sentence. However, until Uzma began hospice, I didn’t realize how much comfort hospice provides, how much life-draining activities it helps avoid. See The Hospice Way To A Good Death for a description.

A hospice nurse commenting on the blog post about hospice delayed says something that captures this:

…I see and hear this every day with my patients I care for in a hospice. And I hear repeatedly “If we would have only known the care we would receive and the focus on living out whatever time we have left with comfort and quality of life, we would have chosen hospice much sooner”

Oncologists Don’t Delay Hospice Purposely

Another comment, this one on a Facebook wall where  Price Of A Bad Metaphor was shared says:

…I worked with hospice for almost 20 years and clearly, most hospice patients come too late to reap the rewards of the care. Please tell me you don’t believe it’s because oncologists are making money on the suffering patients.

Actually no, I don’t believe that oncologists delay hospice purposely to make more money. It is true. Money can create unseen incentives. However, given the known shortage of oncologists, they don’t have to worry about growing their business. They are incredibly caring people. You couldn’t pay most of us enough money to take care of as many terminally ill patients as they do. Uzma’s oncologist was brilliant, kind, compassionate, with great bedside manner and Uzma and I hadn’t the slightest doubt about his expertise regarding treatment choices.

It’s not the profit motive, but the culture of modern America and modern American medicine that is to blame. We have become too enthralled by the technological aspects of modern medicine. Yes, modern medicine is doing amazing things every day. Read about Gleevec® and Sovaldi®, and you will see what I mean. Every truly revolutionary treatment creates hope the next new medication could be them — the next revolution. Most new treatments, whether for cancer or for any other condition, just aren’t revolutionary. They may prolong life by a few months, but that’s it. And, all of them come with serious side-effects.

Though vaccine-refusal and the opioid epidemic might yet change this, the dramatic decreases in mortality over the past 100 years means that all of us — and oncologists are also us — have become uncomfortable talking about death. Oh, we can speak of death in the abstract, alright. But we don’t know how to talk about it with people who are dying and who we care for in some way. We all need to get better at this, but oncologists, who treat so many dying patients, have a particular responsibility to get better at this.

Oncologists Are Not The Only Ones With The Bad Metaphors

Oncologists’ use of the chronic disease metaphor in terminal cancer sucks. As another individual wrote in a comment:

…My Oncologist repeatedly uses this comparison for my Multiple Myeloma diagnosis. Looking at the data avg survival is five years, and I am only 37. I think this is very confusing for my family as it makes them feel that this diagnosis has not significantly shortened my life.”

How terrible for this commenter. Oncologists need to stop using this metaphor.

However, as another commenter pointed out, they are not the only ones using a bad metaphor:

Also the battle metaphor. Not only because it seems to indicate that some didn’t fight hard enough, but also because that fight overshadows the good that can come with focusing energy on the things important to you.

And the people most responsible for the battle metaphor patients, families and advocates. Every battle has a winner and a loser. Stage 4 cancer, by its very definition, has a 100% probability of a foreshortened life. Nobody wants to be a loser. So, to the extent that one keeps buying into this metaphor, the death conversation is not likely to come up.

Uzma Yunus, MD, the creator of this blog died on Jan 30, 2019. About three months before her death, she published her book Left Boob Gone Rogue: My Life With Breast Cancer, which as of this writing has 181 reviews, all 5-star, on Amazon. Her husband, Dheeraj Raina, MD, now maintains this blog.