CHICAGO—Psychosocial and spiritual issues are central to oncology, and physicians can improve their care of their patients by being willing to listen to and address their patients' concerns. So said speakers at a session at the ASCO Annual Meeting here.
“We can all learn more about how to listen to and speak with our patients,” said the session's chair, Alan B. Astrow, MD, Chief of Clinical Oncology at St. Vincent Comprehensive Cancer Center in New York City. Asking about a patient's faith can be a key to establishing better rapport with the person, he said.
“If a Bible or the Koran is sitting on the bedside, it is a clinical clue for you—yet typically these signs are ignored,” said Daniel Sulmasy, OFM, MD, PhD.
Dr. Sulmasy, a Franciscan Friar, holds the Sisters of Charity Chair in Ethics at Saint Vincent Catholic Medical Centers. One way of approaching a patient about religious beliefs, he said, is to start with an observation, ‘So, I see you are reading the Bible.’
As the oncologist, he said, “you should avoid theological arguments: Don't try to redefine hope or a miracle.” But being aware of a patient's beliefs, and being willing to call in a chaplain if it seems appropriate, can enhance a patient's satisfaction with their medical care, he said.
“The heart of healing is being there with the other—this sometimes results in cure and sometimes transition,” said another speaker, Rabbi James Ponet of the Joseph Slifka Center for Jewish Life at Yale University.
At the session, participants focused on a real-life case study. An 85-year-old woman has advanced metastatic breast cancer to the liver and bone. She recently transferred her care to a new hospital and physician, hoping for better results. Nonetheless, her disease is worsening despite maximal hormone therapy and several chemotherapy regimens.
She has increasing kidney failure, heart disease, and is very weak. However, the patient's two sons are unwilling to accept referral to a hospice program, and are upset that the oncologist is “giving up.”
“As the oncologist, you should avoid theological arguments: Don't try to redefine hope or a miracle.” But being aware of a patient's beliefs, and being willing to call in a chaplain if it seems appropriate, can enhance patients satisfaction with their medical care.
They bring in information from the Internet about experimental treatments, but the woman is ineligible for any clinical trials at the medical center. When the oncologist suggests that the patient is too ill to be eligible for clinical trials and that additional chemotherapy would not work, one of the sons expresses anger.
“I'm very disappointed in oncology,” he says. The patient, an African-American, is Baptist, and attends church irregularly. The sons have been seen reading the Bible in the treatment area.
Voting electronically, the physicians at the ASCO session—most of whom said religion was a very important part of their lives—overwhelmingly said they would refer the patient to hospice and respond to the family by discussing their hopes and the realistic approach to treatment.
They further said they would respond to the patient's spiritual outlook by referring the patient and her family to a minister or hospital chaplain, a response that is relatively unusual, according to Dr. Astrow.
The speakers at the session suggested that in cases such as this physicians should talk to the patient as well as her sons, in the hopes of connecting in that way.
One way of establishing an empathetic connection with the sons, and helping them understand your recommendation, Dr. Sulmasy said, is to sit down with them and say, it must be very difficult for you to deal with your mother being so sick.
“I'm struck by the roles of the sons, their unwillingness to accept the inevitable,” said Ingrid Mattson of the MacDonald Center for the Study of Islam at Hartford (Connecticut) Seminary.
In this situation, she said, their racial and religious heritage may play a role. Many African-Americans are skeptical of the medical field because of the historical background of experiments like Tuskegee. In cases such as this, a chaplain might be able to help the patients better understand their own objections to hospice, she said.
Rabbi Ponet said, “In this kind of situation, I would say, ‘I am also disappointed in oncology—-and most doctors are.’”
That doesn't mean that a patient's death should be interpreted as a personal failure, he says, but rather that it is important to tell patients the truth. In this situation, it may be appropriate to say, ‘Look, I've done the best I can, I tell you there is nothing more I can do,’ he concluded.
During the question-and-answer, Judith M. Ford, MD, PhD, a radiation oncologist at UCLA, commented from the audience, “We tend to think that, as oncologists, if we can't do chemo we can't do anything. But good pain control can make people live longer.” Listening can be important, too, she said. “Sometimes the best advice is, ‘don't just do something, stand there.’”
Hope & Anger
Another audience member noted that less than 48 hours before this presentation he had talked with a very ill patient who should be in hospice care. But the patient had instead told him, “I don't want to give up hope. I want to continue chemo.”
One thing oncologists should do in this situation is make sure that chemotherapy is really representing hope, and is not being viewed as just the only way to see the person who has become their primary physician, Dr. Sulmasy said.
“Some patients are afraid of breaking that relationship, as may happen when they go into hospice.” In addition, he said, hope has a lot more to do with meaning than whether you get an extra six days out of a chemotherapy regimen.
In the Jewish tradition, there is a relationship between anger and hope, Rabbi Ponet said. Many patients, though angry with their suffering, will express a willingness to go on hurting because they are open to the possibility that something better can happen. In the Talmud, he continued, this struggle between anger and hope goes on even within God, who is believed to constantly pray, “may my love overcome my anger.”
Understanding how a patient's religious view may influence their perceptions of death and “the good death” can help physicians better treat their patients, the speakers agreed.
In the Roman Catholic tradition, Dr. Sulmasy said, people are taught that it is unseemly to cling too much to life. In this tradition, a good death is a peaceful time of letting go and being surrounded by family and friends.
In Islam, death is fearful for everyone, Ms. Mattson said. “It gives us a sense of urgency,” that we need to accomplish things in this world. Muslims can be fatalistic, she noted, since they typically believe that while the time of death is not something we can know, God does.
Believing in life after death, Islamic scholars posit that just as a child in womb before birth has no understanding of the world to come, people as they die can't possibly understand what life after death will be.
The analogy of a child in the womb is also used in the Talmud to describe life after death, Rabbi Ponet remarked. But unlike Catholics, most Jews find it difficult to embrace death.
“We sit for seven days to mourn, because we do attach and it takes time to let go.…In fact, there's something about letting go of life too easily that can be dangerous,” he said. “Jews put faith in medicine—and multiple medical opinions.”
In cases where patients are hoping for miracles, he said, at least in the Jewish tradition the belief is that miracles happen, but shouldn't be relied on. “The expectation is absurd, yet the hope is important,” he said.
Listening & Respecting
“Always listen to your patients,” Dr. Astrow said. “Try to respect who the patient is and where they have come from.”
“We can all learn more about how to listen to and speak with our patients, and asking about a patient's faith can be a key to establishing better rapport.”
Oncologists meet patients at a particular time in their life, but each patient has an entire life the physician is often unaware of. While it is nearly impossible to hit it off with every patient, he said, “the pleasure and difficulty of a job as an oncologist is that you get to know people at very difficult spots in their lives.”
People, whether religious or not, have desires for meaning, attachment, and love, he concluded. Respecting and inquiring about these underlying beliefs can bring greater satisfaction to patients and doctors.