Ranjana Srivastava’s Essay about Cancer Prognoses, Truth Telling and Ocean Cruises — Illustrates the Challenge of Oncology Practice — and Subtly More

© 2015 Peter Free

 

31 March 2015

 

 

Communicating with dying people challenges compassionate integrity

 

Honest prognosis is not always the best policy, whether as physician or simply friend and relative to someone dying. Yet, there are situations where truth is unavoidable, if one is assist in solving the patient’s implied conundrum.

 

Telling which situation is which is challenging, especially cross-culturally.

 

Oncologist Ranjana Srivastava recently wrote:

 

 

In asking “Can I go on a cruise?” what my patient was really asking is “How long do I have to live?”

 

[T]here are the roughly 20% of cancer patients, often with aggressive disease, who do not want explicit information about prognosis and may suffer psychological harm by being drawn into this discussion by a well-intentioned oncologist.

 

A 2012 study published in the New England Journal of Medicine showed that the vast majority of advanced cancer patients with a poor prognosis did not understand that their cancer was incurable.

 

But tellingly, inaccurate understanding on the patient’s part was related to better communication scores for the oncologist, suggesting that physicians might reveal bad news at their own peril.

 

© 2015 Ranjana Srivastava, ‘Can I go on a cruise, doc?’ really means ‘How long do I have to live?’, The Guardian (31 March 2015) (extracts)

 

Dr. Srivastava concluded her essay with an example:

 

 

“There is this huge ship that leaves at Christmas. It will be nice and warm then.”

 

I take a deep breath.

 

“Tell me about some other cruises.”

 

Her sister takes the hint. “There is the one that leaves soon and it has a mystery island stop off. Our neighbour is a nurse on leave and has offered to come.”

 

“What would you choose?” [the patient] asks . . . .

 

In my choice between the cruise this month and one nine months later lies the answer to her estimated life expectancy so I tread with care.

 

[The patient suggests,] “we can look at the Christmas cruise.”

 

[H]aving closely followed the frightening tempo of her disease and the dignity with which she has conducted herself, I tell myself that I owe her complete honesty.

 

My silence is damning, the wait interminable.

 

Then she rises from her chair, squeezes my hand for what will be the final time, and says, “Thanks, doctor. We have a cruise to catch.”

 

© 2015 Ranjana Srivastava, ‘Can I go on a cruise, doc?’ really means ‘How long do I have to live?’, The Guardian (31 March 2015) (extracts)

 

 

The moral? — Knowing when to be silent sometimes wields Truth’s scalpel more kindly

 

I suspect that the sad softness in Dr. Srivastava’s eyes probably answered the patient’s implied question more than her long silence did.

 

Whether as friends, relatives or physicians — we never know whether our handling of these matters was adequate, much less ideal. I sometimes lie awake, wondering. There is no way to rectify mistakes.

 

Death flays us all, even when we accept its necessity.