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View From the Other Side of the Stethoscope

As an internist and cancer survivor, Wendy S. Harpham, MD, FACP, offers a unique perspective on oncology practices.

Wednesday, September 20, 2023

Finding Purpose

​How often do you think about your purpose? I ask because in today's time-crunched, stressful world of patient care, tapping into the power of purpose may help you hold on to the joys of medicine.

No phone app exists to guide clinicians through the solitary endeavor of finding purpose. Fortunately, privileges of practicing medicine include opportunities to experience vicariously a variety of life challenges and responses. You can test your beliefs about the meaning of life and your purpose, and then reaffirm or revise them. In that spirit, here's my story.

Youthful Purpose

I felt charmed, being one of the lucky few to find my purpose at a young age. My call came to me at my best friend's house while her father and brother argued about whether her mother's rheumatologist knew how much pain she was in and what they should do. Just a teenager at the time, I stared helplessly at the medicine bottles lined up on the kitchen table. That's when I knew: I'm going to become a doctor who communicates well with patients. Thereafter, an image of me in a white coat kept me directed and motivated. I sidestepped existential questions, confident of the meaningfulness and nobility of a career devoted to patient care.

Purposeful Writing

My vision became reality when I opened my medical practice. Seven years later, I lay in bed in pain, overcome with fears about surviving cancer. Reflecting on past conversations with many of my patients where I had felt tuned in to them, I realized that despite my best efforts I'd never grasped the breadth of the great divide. To capture the moment's intensity, I tiptoed into the kitchen that night at 2 a.m. and started writing.

Unlike how I dash off notes, I spent weeks wordsmithing, aiming for lyrical writing that accurately reflected my thoughts and feelings. The effort helped me grieve and adjust; the distraction provided a respite from nausea and leg pain; the finished essay helped a few colleagues understand their patients better, or so they said. Finding purpose in the writing was straightforward. Finding my life's purpose after cancer was not.

General Purpose

What if I die? That question preoccupied me until I began treatment, when my focus shifted to a more hopeful and practical concern: What if I live? Desperate to use my time optimally, I felt unsure about exactly how to do that. Inspirational readings, vivid dreams, and prayers provided fodder for conversations with my Rabbi, my philosopher husband, and close friends. Two themes emerged: The purpose of life is to help others. My purpose is to let goodness flow through me. Whether those were divine messages or soulless expressions of the neurochemical workings of a drugged and stressed brain, they resonated as “right." I was no closer, though, to figuring out how to fulfill those purposes.

Stopgap Purpose

After my diagnosis, I imagine my reaction mirrored how an astronomer abducted onto a spaceship might experience a launch: terrified and curiously excited to visit territory I'd worked earnestly to understand but had tried to avoid myself. My hope for firsthand experience making me a better clinician lessened my fear and grief and boosted my courage and fortitude.

On the other side of the stethoscope, I paid attention to my physical and emotional reactions, and to what helped. Revved on steroids, I began recording insights and tips for a pamphlet for my reception room. My cancer kept shrinking while my list kept growing into a book-length guide for patients. After the manuscript landed me a contract with a major publisher, family and friends cheered, “You're a writer!" I corrected them, insisting I was a clinician using writing as stopgap work until I could resume patient care. And I did, twice, between recurrences. Then ongoing cancer forced me to retire.

Living with Purpose

My worsening prognosis changed my view of most everything. I saw relationships and events through a lens of knowing that one century from now (let alone a millennium from now) not a single person will know the touch of my hand or remember my laugh. That not a single word of mine will remain in print. That the only remembrance of “me" will be a faint echo, a totally unidentifiable ripple effect of my words and actions.

That hyperawareness of my insignificance, combined with eye-opening experiences on the receiving end of others' compassion, had the paradoxical effect of energizing me with a new sense of purpose: fostering hope of moving toward a society that highlights our similarities and not our differences, and where people act on the teaching to “love thy neighbor as thyself." That hope is based on a belief that kind words and actions, like water dripping over granite, can reshape our world imperceptibly through the generations into one of love and peace.

With clarity, I saw purpose in every act of kindness. It mattered less what I did than doing it with kindness. That relieved the pressure to determine a single “right" purpose for me. My job was to embrace the day's challenges–and joys–after choosing from among my many options, a never-ending bounty of opportunities that evolved as my circumstances changed and as I changed. Just as when I practiced medicine, living with purpose was—and always would be—a work in progress.

Finding Purpose

For now, I plan to continue writing to help other patients. As for mundane choices about my time, I keep trying to make wise decisions about whether to sit a bit longer with my 98-year-old mother or help with the grandchildren, attend a virtual lecture or rest, work on my next book or meet a friend for coffee. However a decision turns out, I hope and pray that goodness flows through me.

As a busy clinician, finding or reaffirming your purpose may energize you to meet the challenges. From my perspective, each time you help change a life for the better, you help repair our world. ​

Thursday, September 7, 2023

​Gift-Shop Healing

One of the people involved in my care wore an ID tag with no letters after her name. Unbeknownst to the doctors and nurses on my team at Stanford University Medical Center, she contributed to my well-being during each of my many visits to the lymphoma outpatient clinic in the early 1990s. The now-84-year-old woman and I reminisced during a recent phone call. Our story illustrates healing that happens in unexpected corners of the hospital.

Bea's Story
In 1960, the year after the Stanford campus opened its doors, a young schoolteacher named Beatrice Fioretti (Bea) volunteered to work wherever they could use her. Not counting a break to start her family, her 50 years of volunteering began with escorting patients. She also organized and ordered books for the patient library, which tapped into her professional background. After the gift shop opened in the early 1970s, she began volunteering there, too.

A decade later, with her teenage children rarely home anymore, Bea prayed one evening for a sign: What am I supposed to do now? The next morning over coffee, she found her answer in Stanford's newspaper ad calling for volunteers for a new hospice unit. Experiences at the bedside informed Bea's ongoing efforts in the gift shop. The inventory expanded to include suckers to ease mouth sores and grabbers to preserve patients' reach beyond their beds. Stylish-but-practical loungewear brought comfort to patients tethered to IV lines. Not surprisingly, the inveterate teacher kept the shop stocked with useful books.

It was at the book display in the summer of 1993 that Bea noticed a young woman in a khaki trench coat—me—and gently approached. Hi. How might I help? She didn't only mean with a purchase. She once helped a pediatric nurse snag coveted Beanie Babies. Another time, she housed the parents of a girl with leukemia. When a visiting priest sought community, Bea invited him to attend services with her at her church.

Bea remembers meeting me for the first time. Apparently, I was initially reluctant to engage. Between my choosing a pair of earrings and putting the receipt in my purse, she learned I was hurrying to the motel to call my children before bedtime, two time zones ahead. She also learned I was receiving cancer treatments in a clinical trial and planning to take SuperShuttle to the airport the next day. Bea had another plan in mind. Thereafter, Bea drove me to and from the airport. Sometimes, we ate together, too. As Bea tells it, she gained more than she gave.

Beyond filling her soul by chauffeuring a patient far from home, she would have paid admission to chat one-on-one with a writer about books. She was also fascinated by my personal experiences at the intersection of science and spirituality. Bea treasured our friendship, one strengthened by similarities in how we lived our faiths—Catholic and Jewish—that overshadowed differences. Our talks helped her caring work at the Cancer Center, especially her final ten years tending to hospice patients.

After hearing Bea's reflections, I recounted my memories of those same meetings. Only then did she begin to fully appreciate the gifts she'd given me.

Wendy's Story
Cash was burning a hole in my pocket when I entered the shop. My husband had stuffed $15 in my hand—Buy something fun!—before we kissed goodbye for my first solo trip for treatment. Buckled in at 35,000 feet, mental images of a gift-shop splurge distracted me from images of treatments. The next evening, my call home included the story of my new hot-pink earrings, giving my husband and me a laugh between talking about cancer and kids.

The details are fuzzy in my recollection of Bea's first approach. What I do remember clearly is her car approaching the curb, where she picked up me, my luggage, and our last conversation. Cheerful hellos and hopeful goodbyes bookended the story of our brief times together, talking about everything and anything. Those unfiltered conversations helped me through a journey as emotional as it was geographical. I laughed more, prayed harder, and grew stronger.

Bea's generosity unwittingly helped my husband cope, too. A hoverer, he'd have done anything to simultaneously care for our kids in Texas and accompany me to California. Knowing that Bea would pick me up in more ways than the car ride eased his worry and guilt.

Fortuitous timing led to Bea stepping into my life. How her extraordinary gifts helped me are only half the story. Even if our paths had never crossed, there's something special about hospital gift shops and the people who see their work there as more than a job. Their value hit home for me last year while receiving specialty care at the fourth cancer center of my survivorship journey.

Gift-Shop Healing
After months of weekly checkups for aplastic anemia, I went for my first follow-up in the cancer center's new building. With an hour to kill after my blood draw and unsure what to expect, I checked out the new gift shop. As hoped, its glass door was a wormhole to a world of distractions from needles and test results. Getting lost in leisurely browsing stirred the vacation vibe I enjoy when meandering through art festivals or small-town boutiques—a pleasant feeling of not needing to buy anything but willing to splurge if something strikes my fancy.

While daydreaming at a display case of costume jewelry, a cashier approached me from behind. Let me know if you need something. That familiarly caring tone triggered déjà vu. I turned around and told the cashier, I'm good. Thank you.

Visits to the gift shop have helped with the waiting for appointments, sometimes with a snack to ease a queasy stomach and other times with a splurge on an inspirational knickknack. Even the many times I've left empty-handed, I've felt better, having found what the iconic television character, Norm, found at Cheers: a place to “take a break from all your worries."

As my blood counts have kept inching up, appointments have gotten shorter and intervals between them have gotten longer. One thing has remained the same: visiting the gift shop where the cashier with the kind eyes knows my name. ​

Monday, July 10, 2023

Prescription for Hope: Walking

​An 80-year-old gentleman had recently completed difficult chemotherapy, crossing the finish line in remission. Throughout, he'd pushed himself to take short walks. I asked for his advice to patients about exercising during treatment. Exercise helps you mentally through an arduous time. Don't give up trying to stay active, even when you don't feel like doing anything. Curious, I asked him what had motivated him. Someone who'd been through it told me exercise was important. Otherwise, I wouldn't have known or tried.

That got me thinking. We have consensus in the oncology community that physical activity is safe and beneficial for most cancer survivors. How many patients are not benefiting? Hoping to improve on whatever that number, I'm setting the bar low: Find ways for clinicians to motivate ambulatory patients to walk.

Effective encouragement addresses obstacles patients may face, many of which I experienced over the years of my survivorship. Ideas and mantras that helped me may help other patients.
 
Common Obstacles to Exercising
Bottom line: It's harder to exercise during and after cancer treatment. Imagine gearing up to exercise while queasy, fatigued, grieving, guarding fresh incisions, or dealing with other effects of illness. Time constraints pose an obstacle when the demands of illness keep interrupting or overtaking the daily rhythm of life. Even highly motivated patients may wonder, Where do I find time?

For some patients, safety concerns frighten them off, even when taking walks is not an issue. For athletic patients whose illness makes their usual exercise unwise or impossible, the idea of walking for exercise may feel like another loss, even if only temporary. For sedentary people, the idea may feel like one more unpleasant therapy foisted on them—one more elective than cancer therapy because skipping out doesn't carry the same grave consequences.
 
My Experience With Exercise During Treatment
My first cancer diagnosis challenged everything I knew about my 36-year-old self. Exercising had always ranked alongside eating and sleeping on my list of life's necessities. After peaking as a college athlete, my only exercise while in practice was taking the stairs instead of the elevator while rounding on patients and squeezing in occasional gym workouts.

My chemotherapy in 1990 caused anemia and chronic nausea. To lift my spirits, I wore colorful clothing and cute earrings. On good days, I mounted the cheap stair-stepper in my bedroom. Despite setting the resistance at the lowest level, I tired easily. After 5-10 minutes, I was done.

Exercising at home, like glancing at the mirror before showering, forced on me a self-image of illness. A transient ripple of sadness gave way to a more enduring wave of inspiration. Those measly mini workouts were enough to tap into my inner athlete cheering me on—You go girl!—and help me hold on to my sense of “me." When giving updates, my summary report of symptoms and news proudly included, I'm still exercising, if only for a few minutes.
 
My Experience With Physical Therapy
My experiences with physical therapy (PT), a very different experience from taking walks, helped me further understand the obstacles to taking walks while ill. At the time, progressive marrow failure was stirring fear that my time on earth might be short. My internist had prescribed PT for an age-related back issue.

While driving to my first session, the rain matched my mood as I grumbled about PT encroaching on my happy spaces. I'd gotten darn good at making life the best it could be by not thinking or talking about health when I didn't have to. With the addition of PT, I had to focus on the brokenness of my body while reviewing my medical history yet again, reporting symptoms at follow-ups, and losing chunks of time with sessions and daily home exercises.

On arrival, the physical therapist instructed me to warm up on a stationary bike. Peddling slowly, a thought flashed through my mind: Doctors don't recommend PT to someone dying. I peddled faster, perceiving the prescription for PT as an act of hope for a better tomorrow.

I'd always seen prescriptions as acts of hope. This felt different because fulfilling the hope of PT depended on me in ways that fulfilling that of cancer therapies didn't. With radiation and chemotherapy, I took pills as directed and showed up for appointments, where I let the members of my medical team do their exams, IVs, radiation treatments, whatever. My contribution to the work of killing cancer cells felt passive and the outcome felt out of my hands. Because they were. All I could do was wait helplessly for the test results.

Not so while undergoing PT. The healing agent was not a drug manufactured in a lab or a high-tech intervention administered by professionals. The desired physical changes were triggered by my stretching, my lifting, my pushing, and my pulling. From week to week, my body told me whether the therapy was working. I didn't feel the least bit helpless. Quite the contrary.

Feeling responsible for the success of therapy was good and bad. Regaining a sense of control was very good at a time when so much else felt out of my control. But compliance required heftier doses of willpower and self-discipline than cancer treatments. Let's face it: It was asking a lot for me to muster energy to do boring exercises while feeling sick and to sacrifice “happy" time while feeling urgency to seize the day.

Steps that motivated me to comply with PT may foster patients' compliance with taking walks, such as:

  • Seeing walking as a healing effort under their control.
  • Envisioning doing things made possible by recovery.
  • Making daily walks a “happy space" by listening to music or talk shows and/or by finding a walking partner.

Prescriptions for Walking
These stories illustrate how little it may take to motivate patients. Given the power of your words, it may be enough to say something like: Moving is important during and after cancer treatment. I'm prescribing a short walk every day. This is one way to help your body, especially if you feel tired.
To further inspire and support patients, consider…

  • Informing. Exercise during active treatment has been shown to lessen fatigue; help preserve fitness and strength; and, in some patients, improve quality of life and reduce anxiety and depression (JCO; Vol 40, Issue 22; 5/21/2023).
  • Reassuring. Walking is safe during and after treatment. If you develop problems or ever have worries, stop exercising and contact us.
  • Encouraging. Find ways to make your walk fun or calming. Use it as an escape from illness.

Encouraging ambulatory patients to walk a little may help optimize patient outcomes. That's nowhere near the ideal of prescribing personalized pre-habilitation, rehabilitation, and, where indicated, PT. I'm okay with that. As stated in Moving Through Cancer. An Exercise and Strength Training Program for the Fight of Your Life (Chronicle Prism; 2021): “A little is a lot more than nothing" when it comes to survivors benefiting from moving.​

Thursday, June 8, 2023

​The Problem with Salvage Therapy for Patients Who Fail Treatment

Few problems in oncology have easy fixes. This one does: Medical vernacular unwittingly distressing patients when a phrase means one thing to clinicians and something different to patients. The problem keeps growing in today's culture of healthcare as medicalese increasingly slips into conversations with patients and more patients read chart notes through online portals.

Understanding the negative impact of such miscommunications can guide our brainstorming for alternative language. To illustrate, I'm sharing the patient perspective on phrases commonly used in discussions about persistent or progressive cancer. Suggestions for alternative language provide a starting point for finding and adopting phrases that communicate the ideas equally well while honoring the dictum to do no harm.
 
Treatment Failures
At the young man's visit, his oncologist reviewed the latest scan results. I wish I had better news. The abnormalities are slightly larger. Since you failed treatment, let's talk about what's next. We have good treatment options for this situation. I have hope.

The patient's face flushed, which the oncologist attributed to distress about the news. The caring physician kept the focus on the hope of effective treatments, not realizing that the patient's reddened face reflected shock at hearing “you failed."

What? I didn't fail anything, thought the patient, feeling irritated and somewhat hurt. Indeed, he'd been an ideal patient, having completed every test, treatment, and doctor visit as instructed. He'd taken his medications at home exactly as prescribed. He'd reported side effects and problems in a timely manner. Failed?

The patient didn't dare say anything despite feeling wrongly judged. He wouldn't risk distracting his oncologist or, worse, causing offense. Feeling a need to bite his tongue worsened the sense of vulnerability heightened by the scan results.

Other patients in nearly identical scenarios described to me how after hearing You failed treatment, they also decided to keep mum about the resultant distress. Unlike the young man who rejected the verdict, though, this group of patients took the words to heart. Murmurs of self-doubt and self-blame thereafter rattled around in their head. I failed. I should have eaten healthier. I should have been more positive.

When clinicians chart their notes or discuss cases among themselves, typing or saying “the patient failed treatment" provides a succinct way to express an objective assessment that the disease persisted or progressed despite appropriate treatment. What clinicians mean—and what I trust they believe—is that the treatment failed, and they are not passing judgment about that patient's role in the unwanted outcome. (An exception might be if patients sabotaged their care by skipping treatments or, against medical advice, by pursuing counterproductive measures.)

Understandably, some patients hear judgment. In their world, “you failed" is a charged expression of condemnation. The sentence structure—you failed—puts blame squarely on patients and, even if only subliminally, burdens them with a sense of responsibility. While patient distress in real-time conversations may be offset by the subsequent explanations about their situation, online notes have no safety valve. Think about the potential impact of patients at home reading their chart. In an official document filled with medical jargon, patients are less likely to miss or brush off a black-and-white patient failed treatment— words they think they understand.

A more healing alternative is The treatment failed you. Flip-flopping the subject and object of the transitive verb shifts blame for the failure to the treatment. While better, any reference to failure still risks causing distress by triggering worry that Something caused my treatment to fail, right? Did my physician prescribe the wrong drugs? The wrong doses? Was the therapy administered incorrectly?

These stories of unintended emotional harm suggest that we need a phrase to perform two functions: communicate the fact of an inadequate disease response and put the kibosh on the idea that someone did something wrong. How about this? Since the disease did not respond as hoped, let's talk about what's next. This is something we knew could happen even if you and everyone else did everything right.
 
Salvage Therapies
My journalist friend, Mary, called me with upsetting news. Two years after successful treatment of Stage 2 Hodgkin's lymphoma, routine follow-up tests led to a biopsy. Mary described to me the doctor visit where she learned the results—It's Hodgkin's again—followed by the oncologist's discussion of salvage therapy.

Despite her professional training as an astute listener, she couldn't tell me whether the oncologist had proposed a stem cell transplant (which is what she ended up doing) or offered treatment options. What threw her off was hearing “salvage therapy." Is she talking about a last-ditch effort unlikely to work or that would only yield partial results? Like maybe we could only hope to salvage an arm or a leg! Making matters worse, “rescue therapy" was also used during that discussion, which Mary found equally upsetting. That sounded like a "Hail Mary" pass in football - not likely to work, but hey, might as well try. 

Until then, Mary's knowledge of “salvage" had been in non-medical settings where it means to save from ruin. “Salvage" naturally conjures images where whatever is saved is never the same again. Cargo salvaged from a sunken ship. Furniture and picture albums salvaged from a fire or flood. Marriages salvaged after infidelity.

Mary told me she quickly figured out that "salvage therapy" basically just meant Plan B—the next thing to try after the standard first-line treatment didn't work. Her suggestion for alternative language works well. Because standard therapy did not give us the results we need, we will shift to Plan B. To minimize patients' perception of Plan B as inferior, it helps to normalize changing therapies as a routine path to improvement or, if applicable, cure. We prepare for this situation because some cancers respond better to second-line therapies. Unfortunately, that's something we can know only after trying first-line therapy.

​Over the course of your career, you perpetually update your understanding of disease and recovery, and your use of diagnostics and therapeutics. Words and phrases used to discuss medical matters need updating from time to time, too. As quickly as possible, let's work together to relegate “the patient failed treatment" and “salvage therapy" to the bin of archaic language where “cancer victim" has been collecting dust. Words matter. ​

Monday, May 22, 2023

Helping Patients Let Go

​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.