COMMENTARY

Two Decades in Oncology Don't Afford You Immunity to Grief

Don S. Dizon, MD

Disclosures

July 31, 2020

As physicians, we are trained in life and death: helping our patients live, or live better, and when the time comes, providing comfort to the best of our abilities as they approach their final days.

Don S. Dizon, MD

It's especially true in oncology where, despite ever more options to treat some forms of cancer, many people still die of their disease. After 20 years in the field, I have grown accustomed to this emotional rollercoaster. It's not uncommon to have to break the news to someone that they have stage 4 breast cancer and then go see my next patient to review post-therapy scans and declare them "cancer free."

I often feel like an actor: I have learned to adjust to what the "scene" requires. Except of course that I am not an actor and at the end of the day, I might leave the "set," but I know full well that my patients cannot escape their story.

When I talk with people facing the end of their life, I adhere to my own script. I make a promise with each patient: I will tell you when it's time — when I think you are dying and that medicine can no longer help you.

It's a routine that has served me well and prepares both me and my patient for a future that is without any guarantees. It tells them that I will not purposefully mislead them. I always hope that each patient will beat the odds and be an exceptional responder. I am lucky enough to have a few people who did just that. But more often than not, I find myself sitting with a patient and giving "the talk," counseling them that it's time to stop treatments. I make it a practice to say goodbye when I am cognizant enough to recognize that I won't see a patient again. It's a small part of my routine that helps me keep going as a cancer doctor.

These routines have afforded me protection against falling apart. Every time someone dies of their cancer, I feel the weight of failure, of myself as a doctor and of medicine as a profession. But I learned early enough that I could not survive in oncology with my proverbial heart on my sleeve. No one could bear that kind of emotional weight unabated. So I learned to adapt, and my routines help me with that. Even as I mourn those who've died, I experience the anguish only for a moment, and then I am able to move beyond it.

The 'It's Time' Talk

In principle, this is how I've learned to be an oncologist. In practice, it doesn't always work out this way.

My aunt had lived with EGFR-mutated lung cancer for years. She was fortunate insofar as her tumor expressed a mutation that could be treated with targeted therapy, sparing her the side effects of chemotherapy. I stayed in the background during her treatment, conscious not to play the role of her oncologist. Instead, I was acting only as her "interpreter" when she needed explanations in plain English. She loved her oncologist, but I think was sometimes too shy to ask questions.

These past few months, however, things had changed, and her tumor stopped responding to treatment. She was recommended for a clinical trial, and we spent time discussing what that meant.

"No, you aren't out of options," I explained. "You're being asked to do a trial because this new therapy has promise and you might benefit. You may also be helping someone else living with lung cancer in the future too."

She ended up doing the trial but got very sick. We thought it was the experimental treatment, but it wasn't. It was the cancer. Another treatment was attempted, but symptoms got worse. I knew she was running out of time. I was there when her oncologist told her, "There's nothing more I'd recommend. Anything else would cause severe toxicities, with very little hope you'd benefit from it."

I recognized that this was her oncologist delivering the "it's time" talk. She was devastated.

Afterward, she asked me, "How long do I have?" I'd like to say that my training and experience helped steady me in that moment. But as I looked at her and said, "Months, not years," and watched her cry, I broke too. It devastated me to hear this, as much as it devastated everyone else in my family.

There Is No Immunity From Grief

After clinic one bright day, I decided to visit my aunt. She had started hospice a few weeks earlier, and I had the urge to visit. She lay in her hospital bed peacefully. I learned how her decline had been precipitous, that she had been agitated but was now at rest. I spoke to others in our family and then stood by her bed, seeing if she would wake. She didn't. I prayed a silent prayer and then went home. She died the next day.

I thought my years in oncology would have afforded me immunity to grief, to accept death as a part of life, and to move on readily. But it hasn't. Truth is, I haven't gotten used to any of it — to having the "it's time" talks about the end of life, to signing death certificates, to reading the obituaries of those whose lives ended too soon. And I now know one other thing is also true: I never will.

Don S. Dizon, MD, is an oncologist who specializes in women's cancers. He is the director of women's cancers at Lifespan Cancer Institute and director of medical oncology at Rhode Island Hospital.

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