Harpham, Wendy S. MD
WENDY S. HARPHAM, MD
When caring for a newly diagnosed patient with a poor prognosis, do you have a professional obligation to feel hope for a good outcome?
I've always answered “Yes” without hesitation, a conviction sparked after a Grand Rounds update on pancreatic cancer decades ago. Leaving that forward-looking presentation, I overheard an attendee mutter, “They're all gonna die anyway.” My distress over that physician's glib hopelessness, intensified by my own desperate need for my doctors to feel hope for me, generated my enduring assumption: Clinicians' hope improves the care of patients.
In my efforts over the years to help patients as a co-survivor (and not as a doctor), I've purposely bared my hopeful heart. So my uncharacteristic reaction to a woman, reeling from her dire diagnosis, surprised and unsettled me. Feeling empty, I strained to stay on-task, mechanically offering tips on helping her teens—at least, that's how it felt to me.
My hopelessness was hardly a case for Sherlock. Miles away but forefront in my mind, the funeral of a different young mother was about to begin. I'd expected that tragic outcome throughout the months of e-conversations about helping her children. But I had truly hoped for that mother to be the exception, letting go of my hope for a happy ending only when changing circumstances made hospice her best option.
Concerned that my hopelessness born of grief over the death of one woman had bled through my efforts to help a woman whose journey had just begun, worried that I might even have caused harm, I felt compelled to justify to myself why: Why does healers' hope matter?
Certainly, in the trenches of clinical medicine, you can help patients without feeling hopeful yourself. Dispassionate recommendations and therapies save lives. Kind words and gestures benefit patients, too, even if just Oscar-worthy acts because you're running on vapors at the end of a tough on-call or feeling emotionally numb after losing a patient unexpectedly.
As proof, not long after hanging up with that newly diagnosed mother, I received an email filled with thanks for my “uplifting” words. She had heard my hopeful message and not my hopeless heart.
Whew. It's great that we can help patients without feeling hope ourselves. But that doesn't make healers' hope unimportant. That doesn't mean it's okay if healers feel hopeless. Why so?
My answer begins with a definition of hope: a pleasant feeling associated with your belief that a future good can happen. We must keep in mind that “hope” is not one thing, but an umbrella term for a vast and complex array of feelings, each dependent on multiple factors, such as the object of your hope and your role in affecting the outcome. Hope to cure is different from hope to provide excellent care. A clinician's hope for cure is different from that of a patient's.
Hope contrasts with expectation, the feeling stirred by your acceptance of the likely outcome based on all available predictive indicators. More than anyone else in a patient's life, you have an obligation to maintain enough objectivity to expect the statistically likely outcome for that patient—even while trying to prevent it with your recommendations and prescriptions—and to prepare yourself mentally to respond to whatever happens.
Now let's turn our attention to clinicians' hope for a newly diagnosed patient with a poor prognosis. Given your obligation to maintain objectivity and to expect the likely outcome, what good does it do to nurture your hope, again and again, that this new patient in front of you could be the exceptional person whose cancer responds fully to treatment and never recurs?
In a nutshell, hope is a feeling. And like all feelings, hope shapes our perceptions of reality and our responses. At the bedside, your hope may help you bring your best game to each case by priming your eyes, ears, and fingers to pick up tiny clues that lead you to earlier diagnoses and guide optimal supportive therapies. Such hope-driven attention to detail may give some patient the edge needed to land on the good side of grim statistics.
Hope may energize you to go beyond the call of duty. You never know when attending yet another conference, obtaining yet another curbside consult, or reading yet another article will open your eyes to a new clinical trial or off-label therapy that may help some lucky patient.
If nothing else, since emotions affect facial expression and tone of voice (including that of professionals), hope-infused words and actions may communicate compassion more effectively. Compassion fosters the trust that gives added weight to your recommendations, encouragement, and words of comfort. Thus, indirectly, your hope may help patients make wise decisions, comply with therapies, exercise, eat healthfully, and engage ineffable factors in healing such as the will to live—all of which, somehow, result in their riding the tail end of the survival curve. Your hope may help them hang in there, still sick but well enough to benefit from better therapies that come along.
Even if the ripple effects of your hope never save a single additional life, your inspired efforts may improve countless lives by strengthening patients' confidence in their care. Patients who know you began their ill-fated journey with hope may find it easier, later, to accept your assessment that hospice is now the most hopeful step. Terminally ill patients who remember the tests and therapies you prescribed with hope may be spared the added burden of doubts and regrets, finding peace in the knowledge they had the best chance… that no stone was left unturned… that you cared.
For these reasons and more, I wish you the courage and strength to nourish your hope for the best possible outcome as you begin each journey with a newly diagnosed patient.