The young chaplain's intensity reminded me of the thrill I'd felt as a third-year medical student successfully completing a “first.” First intubation. First lumbar puncture. For sure, the spiritual young man felt sad about the young mother's death, having counseled and prayed with her since her cancer diagnosis two years earlier. At the same time, though, he was excited to share his experience midwifing her dying by gently whispering in her ear that It's okay to let go.
The chaplain's story tuned me in to the power of the idiom—let go—in helping patients when letting go of something is both necessary and difficult for them. In oncology, that idiom holds great potential when making difficult decisions about school, work, family planning, and hobbies too dangerous or no longer realistic due to cancer-related changes. It may also facilitate discussions about treatment options like mechanical ventilation, dialysis, chemotherapy, and investigational therapy.
Unfortunately, using the idiom may backfire because of the various meanings of “let go.” It would be a shame to avoid such a powerful tool in patient care. Instead, let's do a quick dive into the ways patients may interpret it. This exercise may help prevent miscommunications and, even better, thereafter enhance the idiom's healing potential. For now, let's narrow the scope to discussions about stopping cancer treatment.
One meaning of “let go” is “to stop trying to control something.” Patients who thrive on battle imagery may assume the “something” you are referring to is their “fight.” They hear you advising them to give up, surrender, and lose the battle. Other patients may assume you mean “the cancer” and are suggesting they invite malignant cells to wreak havoc and then kill them. Either way, patients feel disempowered by the idea of no longer trying to influence their fate.
“Let go” can also mean “to stop having or owning something,” such as letting go of a grudge or letting go of your favorite flannel shirt by donating it. What might patients think you want them to stop having? Since their diagnosis, one thing hammered into them as a must-have is hope. Here, a suggestion to let go may feel l like a stab to the heart, leading patients to despair. Some patients may get angry, silently daring you to try to pry away their hope.
Yet another interpretation is “to choose inaction.” Imagine you are walking with a handful of coins, and a nickel slips through your fingers. You can choose to let it go and keep walking instead of stopping to retrieve it. With that idea in mind, patients may interpret “letting go” as leaving stones unturned. Are you neglecting options such as early-phase clinical trials or off-label therapies?
Yet another meaning of “let go” is “to overcome inhibitions” and give free rein to instincts. I'm reminded of a time when, with nobody else at home, I let go of pent-up distress by cursing and wailing at the top of my lungs. The primal release scared me. That letting go also freed me.
As a cancer survivor, the interpretation I find most useful is “to overcome instincts to hold tightly to something.” If sitting atop a playground slide, letting go enables you to enjoy the ride. If embracing a loved one at an airport, letting go enables you to begin your planned journey. Those images of letting go connote autonomy and courage. You are choosing to release your hold to venture forth. Importantly, the images illustrate the tension between the comforting reassurance of holding on and the disquieting anticipation of letting go. In discussions of stopping treatment, acknowledging the fears, sadness, and other negative emotions associated with letting go may be instrumental in helping patients benefit from the positives: no more side effects, inconveniences, and time toxicity of treatment.
Whichever meanings resonate for patients who ultimately choose to stop treatment, letting go necessarily involves loss. It's not easy saying good-bye to the people who got them to today—the physicians, nurses, PAs, NPs, MAs, phlebotomists, and scheduling clerks with whom they have developed deep bonds. Acknowledging the losses encourages healing grief.
Given all those meanings, the challenge for clinicians is avoiding miscommunications during discussions about stopping treatment. When introducing the notion of letting go, consider...
- Clarifying exactly what to let go of: The only thing we're letting go of is the hope that available cancer treatments can improve the situation. For now, further treatments only hurt.
- Emphasizing benefits of letting go: We expect you to feel better off treatment than if we continued. Many patients like you live longer than similar patients receiving futile treatment.
- Finding a useful metaphor: Imagine your wallet contains a wad of paper bills, each with a different denomination representing a different hope. The $1,000 bill represents hope that more cancer treatments can help you. Sadly, that bill is shredded. Patients who let go of the worthless bill can focus on using the remaining bills to make life the best it can be.
- Acknowledging patients' grief: Letting go is sad. It is more sad when patients keep holding on and suffer avoidable pain.
- Shoring up patients' courage: Letting go can feel scary. You've made it through tough times and difficult decisions before. You have what it takes.
- Relieving patients of undeserved guilt or shame: I want the best for you. I believe you are doing the right thing now by letting go of cancer treatment.
- Leaving room for hope of recovery: Things happen in medicine that we don't understand. On rare occasions, the course of a patient's illness surprises everyone and the patient's condition improves, at least for a while. I'll keep my eyes open for new treatments. I'll keep hoping you do as well as possible.
- Voicing your commitment: I am not letting go of caring about you, no matter what you decide, and no matter which professionals care for you.
At times, letting go is essential to getting good care and living as fully as possible. If patients find letting go daunting, you are in a uniquely powerful position to help. With authority and compassion, you can introduce the idiom—let go—as a voluntary process that empowers patients to make life the best it can be. Your guidance and support in the difficult task of letting go help patients experience the peace that comes with making wise decisions and adjusting to their reality in healing, hopeful ways.
WENDY S. HARPHAM, MD, FACP, is an internist, cancer survivor, and author. Her books include Healing Hope—Through and Beyond Cancer, as well as Diagnosis Cancer, After Cancer, When a Parent Has Cancer, and Only 10 Seconds to Care: Help and Hope for Busy Clinicians. She lectures on “Healthy Survivorship” and “Healing Hope.” As she notes on her website (wendyharpham.com) and her blog (wendyharpham.com/blog/), her mission is to help others through the synergy of science and caring.
Oncology Times offers helpful handouts on a wide-range of oncology topics, including: A Healthy Approach to Online Test Results, When Your Child Is Diagnosed With Cancer, and Coping With Treatment Delays. You can download all patient and clinician handouts at https://bit.ly/2FE9g6K.