If your patient has exhausted all treatment options or if your patient is close to death, do you say anything about letting go? I'm asking because in a recent post on WebMD's “Cancer Realities,” oncologist Richard Frank reflected on his responsibility to tell certain patients, “It's okay to let go.”
Since reading his piece, I've marveled at the number of times over the course of a day I use the idiom “let go” and how it means different things depending on the situation. Naturally this got me thinking: What do your patients hear if you tell them it's okay to let go? It may not be what you intend.
One definition is “stopping trying to control something.” If discontinuing antineoplastics, patients who've thrived on battle imagery may assume “something” is their fight. For them, letting go means giving up, surrendering, and losing the battle. For others, the first “something” that comes to mind is “cancer.” These patients think you expect them to stop trying to control their fate—essentially inviting uncontrolled cancer to kill them.
“Letting go” can also mean “stopping having or owning something,” such as “letting go” of your favorite flannel shirt by donating it, or “letting go” of a grudge. What might terminally ill patients think you want them to stop having? The one thing that has been hammered into them as a “must-have” when living with cancer: Hope. Thus, letting go can feel like a stab to the heart, leading patients to despair. Or they may get angry, silently daring you to try to pry away their hope.
Yet another definition is “choosing not to take action.” If some coins slip through your fingers, you may walk away—let go—instead of bending over to retrieve the money. It's possible patients interpret “letting go” as choosing not to pursue viable options, such as clinical trials or off-label chemo-cocktails.
People also use “letting go” to mean overcoming the instinct to hold tightly to something. If sitting atop a playground slide, you “let go” to enjoy the ride. If hugging your beloved at the airport, you “let go” to board the plane.
Interestingly, “letting go” also can mean overcoming inhibitions and giving free rein to your instincts. I'm reminded of a terrible time when, with nobody else at home, I “let go”—cursing and wailing.
Whichever definitions resonate for patients when stopping treatment, “letting go” necessarily involves saying good-bye to the people who got them to today—the doctors, nurses, techs, and even scheduling clerks with whom they have developed deep bonds. How sad.
Yes, letting go is sad. I remember the sorrow of “letting go” of my medical practice when I needed more treatment.
Like grieving, “letting go” is not a single act but a process—whether letting go of hopes or of connections to others. As Frank wrote, “It takes time to achieve a sense of peace with the events that are unfolding beyond anyone's control.”
Thinking about this column has led me to see “letting go” not only as the best choice in a variety of circumstances, but also as an essential element of patients' ability to get good care and live as fully as possible after stopping treatment. Only by letting go can patients respond to their situation in healing ways.
Later in patients' journeys, as the end draws near, dying is natural. Letting go is not. You and I can only imagine letting go of everything we know and love, and facing death. That's okay. We can still help.
The challenge for clinicians is how to present the notion of “letting go.” Here are some thoughts:
* Clarify exactly what you are encouraging them to let go of: “We need to talk about the hope that cancer treatments can help: That hope is gone. For you to get good care, we must let go of that particular hope. More cancer treatments can only hurt you, no matter how much courage, fortitude or will-to-live you have.”
* Since metaphors often help where facts fail, find one that works for you: “Imagine holding a stack of dollar bills, each with a different denomination. These bills represent your different hopes. The one bill worth $1,000 represents the hope that more cancer treatments can help you. Unfortunately, this bill has been completely shredded and no longer has any value. To live well, you must let go of that worthless bill and focus on the intact bills that remain.”
* Emphasize life-enhancing hopes: “We have good reason to hope you'll feel better off treatment. We can hope to maximize your comfort, preserve your dignity, and do all we can to make every day the best it can be.”
* Crack open the door to hope for recovery: “I'm not letting go of hope for recovery. I'll keep my eyes open for new treatments that might be worth a try. On rare occasions, a patient surprises everyone and gets better, at least for a while. I'll keep hoping you do as well as possible.”
* Acknowledge patients' grief: “Letting go is sad. But it is sadder if patients don't let go and consequently suffer unnecessary pain.”
* Shore up patients' courage: “We know this is hard—and scary. We also know you've made it through tough things before. We are here for you.”
* Relieve patients of the added burden of undeserved guilt or shame: “The time has come to let nature takes its course. You are doing the right thing to let go of fighting... to let go of suffering. It's really okay to let go.”
Of course, when it comes to letting go, it's not only patients who need courage and strength. With respect for the work you do, I wish for you the courage and strength needed to help your patients let go and die peacefully.