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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.

Friday, April 5, 2019

Checking Out God's Hotel

​Assuming your patients' physical improvement is possible, how do you see yourself facilitating that healing? Surely you don't envision realigning four humors, as did healers in premodern times. Do you believe you're nursing a life force separate from the physical body? Your answers matter, because your understanding of illness and healing guides your care of patients.

In God's Hotel: A Doctor, A Hospital, and a Pilgrimage to the Heart of Medicine, Victoria Sweet uses deftly painted patient vignettes as scaffolding for a provocative discussion of clinicians' role in healing. The book opens with Sweet's disappointment as a third-year medical student watching the conclusion of the autopsy of one of her patients. "I'd expected (we'd find) some thing that was, well, ineradicably Mr. Baker, something the pathologist's (electric) saw could not open and destroy."

It wasn't until years later that Sweet realized modern medicine had no language for a patient's "life force," and premodern medicine did. Ancient terms such as "spiritus" and "anima" referenced "something present in the living body but missing from the corpse." Rest assured, God's Hotel is not a treatise about the soul or religion. This is the story of Sweet's earnest attempt as a scientist to reconcile the mysteries of healing so she could optimize her ability to help patients.

Sweet's efforts began informally while working in a rural private practice, and they continued with a stretch as the director of a community clinic. Then Sweet took a road less traveled, working for decades as a primary care physician at Laguna Honda, America's last almshouse. On the wards, she relished the slower pace and autonomy that long-retired physicians fondly recall and young physicians can only imagine. The gifts of Laguna Honda—its unconventional floor plan, a head nurse who knitted blankets for patients, and enough time to just sit and watch a patient—highlighted elements of the healing arts now threatened by technology-rich, rushed patient care.

What separates God's Hotel from other vignette-heavy clinician memoirs is Sweet's expertise as a PhD in history and social medicine. She learned German and Medieval Latin to explore original texts on the work of Hildegard, a 12th century German practitioner of premodern medicine (as well as a nun, mystic, and theologian). Sweet's academic effort was motivated by her desire as a clinician to find insights from a time when healers believed in viriditas—"the power of humans to grow, to give birth, and to heal."

Whenever diagnosing and treating patients, Sweet turned to the medical truths revealed by science and technology to inform her prescriptions. At the same time, she feared modern medicine's mechanistic approach suffered from rejecting (or ignoring) the notion of a life force. In Hildegard's writings, Sweet found ideas that opened opportunities to foster healing—and humanism—in modern medicine.

Here's an example. As the admitting physician, Sweet assessed Terry Baker, a heroin addict and prostitute with transverse myelitis and a massive inoperable decubitus. Facing "a catastrophe, and possibly the end of Ms. Terry Baker," Sweet tried a Hildegardian approach to healing by "removing all obstructions to Terry's own viriditas."

Please stay with me, here. As expected in a book like this, Terry makes a remarkable recovery, her vast wound healing by secondary intention, thanks to repeated debridement and proper dressing, healthful nutrition, rest, physical therapy, and her quitting smoking. And tincture of time: two and a half years of expert and compassionate care at Laguna Honda.

You could argue that Terry would have recovered had she received the same care from a physician who'd never heard of Hildegard but prescribed the same therapies. I agree. That argument, however, misses the point: Without a premodern concept of viriditas, Sweet likely would have been less persistent and holistic with the many little efforts she took to facilitate Terry's healing.

It's easy to get misled when you read that Sweet, despairing about Terry's prognosis, asked, "What would Hildegard do?" To put that comment in context, Sweet later emphasized how her intimate knowledge of Hildegard led her to feel "even more grateful for modern medicine...especially for its scientific method, which tests the past, rejects what is ineffective, improves on what works, and passes to the future its powerful results."

Sweet doesn't ask you to share her belief that a life force enters the body with a baby's first breath and leaves with the final expiration. Nor does she suggest that viriditas emerges from biochemical processes (analogous to the notion that consciousness emerges from brainwave activity) and disappears at death. Through stories and discussion, she encourages you to swim against the tide of mechanistic commoditized care and embrace the mysteries of life and healing. She presents her case for clinicians to continue capitalizing on the truths revealed through modern science, while integrating aspects of premodern medicine that can serve patients—and clinicians—well today.

Premodern medicine has no place in patient care. What it can do for today's clinicians is what Hildegard's writings did for Sweet at Laguna Honda: offer inspiration and timeless lessons about the value of observational skills, patience, diet, exercise, meaning, connection, community, and tending to the little things.

This complex book devotes a few pages to Sweet's 1,200-mile pilgrimage on foot to Santiago de Compostela. She began that journey with hope of better understanding "otherness" and tasting 12th-century living. Through the hardships of that pilgrimage, she learned to expect the unexpected, find peace in the waiting, and feel satisfaction with "things as they turn out to be"—invaluable lessons for clinicians.

Throughout the book, Sweet weaves the saga of the demise of the original Laguna Honda and the transition to a modern facility. Here, I found her storytelling tedious. Still, those sections helped me think about the relationship between nurses and physicians, and about the roles of architectural and administrative structures in the healing equation.

God's Hotel offers a fresh way to think about the challenges of modern patient care. You'll reaffirm or modify your understanding of what, exactly, you do to facilitate patients' healing. And you may find practical ways to improve your care.

Wednesday, February 20, 2019

Helping Patients Cope With Losing Things

​Patients with cancer-related cognitive impairment (CRCI) may never tell you about their trouble with losing things. Compared to recurrent cancer and chronic pain, misplaced keys and lost checkbooks are no big deal. As for those patients who do mention it, what can you say?

A helpful response depends on understanding not only the symptoms of CRCI and differential diagnosis, but also the darker side of constantly losing things. Here's a glimpse of my struggles and the insights that help me cope. I share them with the hope that they help you find healing words for your patients.

Before my cancer diagnosis, sunup-to-sundown multitasking defined my life as a young internist and mother of three. After various courses of cancer therapies, balancing life became almost impossible due to cognitive impairment: difficulties with attention, word and memory retrieval, working with numbers, topographical agnosia, information-processing speed, and impaired short-term memory.

Just as a sore bruise on my funny bone made me aware how often I lean on my elbow, my CRCI exposed my dependence on short-term memory to navigate the world and be "me." I burn extra calories walking into rooms and then wondering why I'm there. Sometimes I'm rude during conversations, interrupting with my thought before it slips from my mind. And I misplace and lose things every day.

This is my understanding of why I keep losing things: it's as if my brain no longer sees the whole picture, or it sees it but later can't retrieve it. Like a camera zoomed in on a subject, my brain creates easily retrievable engrams only if I'm focused on what I'm seeing and doing. Consequently, when I try recalling past events, a blank slate replaces images of what I did automatically, as well as the sights and sounds I experienced peripherally.

If it's important for me to recall some event or action, concerted effort and time may produce useful images. Or, if I'm presented with evidence (i.e., someone remembers seeing what I did with the misplaced object, or the item turns up), a memory of it might emerge. Too often, it remains amorphous.

I accept my CRCI as a cost of my survival. Had I known upfront I'd develop this aftereffect, I'd have proceeded with the same treatments. Still, painful thoughts and feelings arise when surprised by a loss, for reasons I'll illustrate with a story.

Ding Dong. Before opening the door for a photographer a few months ago, I quickly went to my jewelry box to grab my signature "Hope" necklace to wear for a magazine photo shoot. Surprise! The handcrafted piece wasn't where I usually keep it. "No big deal; I'll find it tonight," I reassured myself while grabbing another necklace.

Well, I didn't find my "Hope" piece in my jewelry box. Nor did I find it after calling the hotels I'd visited since the last Facebook proof of wearing it, searching on my hands and knees with a flashlight in my bathroom and around my dresser, or going piece by piece through every necklace and bracelet I own, twice.

To help me move on, I concluded it was gone and recited my trope "It's just a thing." Yet, thereafter, my morning accessorizing routine included briefly searching through my necklaces and bracelets for my silver "Hope."

That irrational searching was fueled by more than missing my one-of-a-kind necklace. I wanted to live in a world that made sense. Where books and wrapped gifts didn't just disappear. You see, a reliable physical world helped life feel normal after cancer. Each time I lost something, the physical world seemed uncertain, which exacerbated the rumbling anxiety of knowing (the way survivors know) that life is uncertain. I yearned for an end to the little losses that kept reminding me of the inevitable great loss.

Wow, that sounds awfully melodramatic. After all, everyone loses things now and then. This is different.

Before developing CRCI, I took losses in stride. Now they trigger exaggerated responses because they keep throwing me off balance. It's like when you go downstairs and—aaaahh!—almost fall because you thought you'd reached the landing when you had one more step. My efforts to do things and go places are repeatedly interrupted by the discovery of losses that drop me to my knees, wasting precious time on another search.

These days, I calm the unpleasant thoughts and feelings rather quickly when home alone. If with family when I lose something, it's still distressing. All heads turn toward me, even if I had nothing to do with the item gone missing. I don't blame them: I also assume it's my fault. Even though my family is extraordinarily gracious and understanding, it hurts to watch them searching, too—my loss now our loss.

Here's the good news: patients can do a lot to decrease their risk of losing things. I'll devote my next column to a patient handout filled with insights and tips, some of which might be useful during an office visit, such as...

  • Your "losing things" is real, and it's different than normal "losing things" experienced by healthy, busy people.
  • This is not your fault; it's a cost of your survival.

CRCI is an invisible wound that can make life difficult. Patients who mention that they are "losing things" open up opportunities to improve their care. After validating patients' distress, you can determine whether there's a need to evaluate for other causes of cognitive impairment. Maybe you can adjust their medications. And you can guide them to resources that help them accept and adjust in healthy ways. In doing so, your expert, compassionate response helps patients live their best life.

Months ago, I stopped looking for my "Hope" necklace. That letting go saved time and brought me peace. I also found peace by embracing the mystery of where the necklace ended up, using the loss as a reminder to embrace—not fight or fear—the mystery of life. I moved on. Unexpectedly, while getting dressed last week I lifted an old bottle of lotion and couldn't believe my eyes: a silvery glint of "Hope" on a chain.

Monday, January 7, 2019

Patients' Hope for a Miracle

​What's the best response to patients who express hope for a miracle? When I was in practice, I usually said nothing. My tongue was tied with fear of saying something that might foster false hope or come across as demeaning. Besides, my training made clear that faith was beyond the scope of medicine.

In retrospect, I wish I'd found a way to acknowledge patients' references to miracles, especially in cases where patients had bumped into the limits of modern medicine. Surely I missed opportunities to guide patients toward healing hope—realistic hope that helps patients live their best life. That leaves me with the challenge of finding a response that can help and not harm the patients who now reach out to me as a co-survivor (and not as their physician).

My search for healing words begins, as usual, by typing "definition miracle" in the Google search bar. The various definitions only create more questions. Do patients who talk of miracles mean they believe in outcomes contravening natural laws and the order of nature? If so, are those patients telling me they believe in magic or supernatural beings? Or are they taking a more biblical stance, sharing their faith that miracles have a clear explanation: God swoops in with acts that supersede natural law, His divine intervention shaping human affairs.

Then again, people often use "miracles" in more earth-bound terms, such as when someone says, "The traffic was so awful, it's a miracle I arrived on time." Patients who mention hope for a miracle may intend nothing more than hope of achieving an unlikely—but possible—good outcome.

Lastly, patients may simply be referring to the wonder of life. Everyday "miracles" surround us, from sunrises and sunsets to icicles adorning tree branches in the winter and crocuses popping through hard earth in the spring.

To complicate matters in tough situations, a variety of reasons (often subconscious) may prompt patients to tell you they're hoping for a miracle. For some, "I'm hoping for a miracle" is a way to ask for validation they heard you right...that the likelihood of the unwanted outcome is as they feared. They're pitching you a chance to clarify any misunderstanding: "No, no, we don't need a miracle. Many patients recover with the recommended therapies."

Other patients know they heard you right. They're just not yet ready to believe the unwanted news. For them, the language of miracles may serve as a stepping stone through the transition to acceptance. It's emotionally easier to say, "I'm hoping for a miracle" than to say, "Cancer treatments can't help anymore" or "I need treatment that will likely cost me my fertility."

Still other patients accept their new reality but may be struggling with "What can I hope for now?" Talking about hope for a miracle helps them hold on to their overall hopefulness while grieving the loss of specific hopes and working their way to new hopes, such as hope to become a parent through adoption or, at the end of life, hope to make the best of each day.

The good news for clinicians is that whatever patients mean by "miracle" and whatever the impetus for their comment, they generally need the same three things from you: 1) sound information about their condition and options, 2) your assessment of both the prognosis and the best possible outcome, and 3) guidance in their efforts to find healing hope. At times (not always), patients' reference to miracles may offer an opening to fulfill all three needs.

If magically I were back in practice and patients mentioned their hope for a miracle, I'd consider responding by...

  • Acknowledging their comment. I'd try to find some way to let them know, "I hear you."
  • Sharing my wishes for them. I might follow up with, "I wish I could write a prescription for a miracle" or "I wish I had a magic wand to speed up today's research." The image of fantasy wishes provides a gentler way to clarify and reinforce upsetting facts, and to do so with compassion. Wishing reflects disappointment, an emotion that shows I care. And the focus of the wishes on the limits of available therapies may help prevent patients' regret about past decisions.
  • Highlighting the uncertainty. I'd open the door to realistic hope by saying, "On occasion, things happen in medicine that we don't expect and can't explain." To minimize the risk of fostering false hope, I'd spell out the difference between expectation and hope, and then remind patients "You can accept the likely outcome while hoping for the best possible outcome."
  • Reassuring patients of my commitment. I'd offer a variation of "prepare for the worst and hope for the best." Here's an option that avoids the directive while sending the same message: "I'm prepared to care for you, whatever happens. While expecting the likely outcome, I'm hoping for the best possible outcome for you." If appropriate, I'd add that I'd be thrilled if their cancer proves my prognosis wrong.

A huge challenge in oncology is the frequency with which you care for patients in heartrending situations, from patients with options that, while curative, will likely cause permanent life-altering losses, to patients whose only option is a Hail-Mary intervention, if they have any options at all. Without a magic wand, the best you can do is prescribe the best therapies for each patient and hope for the best.

Meanwhile, those patients need hope, which may seem elusive. Patients' mention of hope for a miraculous recovery may be your cue to offer information and inspiration. What you say—and don't say—matters. A caring response may help them adjust to their new reality and move forward with hope that helps them get good care and live as fully as possible today, tomorrow, and every day.

Monday, October 22, 2018

Beautiful Crutches

​Compared to surviving cancer, needing some sort of crutch to get through the day is no big deal. Unless it is. After completing cancer treatments, some patients balk at using any aids that could make life easier, safer and, one would assume, happier. I sympathize. Early in my survivorship, I resisted using any crutches, even though what I needed was far less conspicuous than a walker or compression sleeve. Here I'll share the experiences that transformed my perception of such aids—and of myself. Maybe my story will be useful in your care of patients who refuse to take advantage of available aids or use them reluctantly and unhappily.

The first time I needed crutches—the forked-metal-struts kind with a crossbar for the armpit—was as a medical student nursing a swollen ankle. The clock ticked away as I hobbled from one tagged display to the next for my anatomy final. I hated those crutches that slowed me down.

Decades later, I needed a different kind of crutch. My injury was not a temporarily swollen joint but post-cancer fatigue and cognitive deficits. For months, I seemed to spend more time looking for my keys than driving. While running errands, my insistence on relying on my faulty memory led to mistakes that distressed me, especially when my goofs inconvenienced other people.

I didn't need a medical degree to know life would be better if I attached my keys to my pocketbook and used checklists for errands. Yet I stubbornly resisted using any aids, setting in motion a vicious cycle of feeling and functioning worse and worse until my invisible wounds wore me down and threatened my sense of self.

The reason for my resistance can be summarized in an aphorism found in my book, Healing Hope: "Illness makes smart people do foolish things." To be fair, my jokey response to a serious problem helps patients like me save face and move on without exploring the psychological and emotional terrain of our unwise decisions.

It's worth taking a moment, though, to consider possible explanations for patients' resistance to using any sort of crutch. Patients may feel daunted by the rigmarole of acquiring and learning how to properly use it. There may be a burdensome expense.

Beyond practical matters, crutches spotlight a debility—to the patient, if not to the world. Patients' resistance to using crutches may reflect their desire to…

  • Maintain control over "something"
  • Hold on to their "non-cancer" self-image
  • Not be reminded of their loss
  • Avoid accepting another loss and experiencing grief

In addition, patients may fear using anything "as a crutch," with that pejorative connotation of leaning on an aid excessively. If struggling patients are impressed by stories of mountain-climbing survivors, they may berate themselves and wonder, "Am I trying hard enough?"

For me to function more normally, I needed ordinary memory aids. That I hesitated at all highlights one of the challenges for patients whose cancer or treatments cause significant injury: Patients may have to grieve their loss as a step toward accepting it. They may have to work their way to seeing themselves as whole.

Fortunately for me, at my first survivorship event I met a middle-aged woman with a hearty laugh who had accessorized her colorful clothes with an equally colorful, matching-fabric eye patch. After barely surviving recurrent childhood retinoblastoma and suffering failed prostheses, she'd embraced her differentness with a creative flare.

Her example helped me hear—and believe—words of encouragement, such as…

  • You are not your crutch.
  • Using a crutch when you need one is different than using something as a crutch when you don't need one.
  • Choosing to use needed crutches is the same as choosing to make life the best it can be.

Prioritizing my hopes helped, too. I asked myself which I hoped for more: avoiding crutches or avoiding problems. It was a question of values: Did I care more about how I looked or how I functioned?

My hope to live my best life prompted me to go to a hardware store and buy a pink stretchy plastic spiral coil for my keys and a purple one for my wallet. Since that day, no more looking for misplaced keys. No more worrying about leaving my wallet on a store counter. When my cellphone alarm reminds me where I'm supposed to be, I simply grab my pocketbook and my cellphone with my digital checklist, and I confidently head out the door.

Looking back at my experience of hobbling through the anatomy final, I didn't hate my crutches. I hated my sprained ankle. Thanks to my crutches, I finished the semester on time and my ankle healed.

Today, every time I pick up my pocketbook I smile with relief at the sight of my plastic coils in my favorite colors. I feel grateful for—even proud of—this crutch that decreases my stress and helps me live my best life, a life made possible by my treatments.

Comprehensive cancer care includes helping patients overcome practical and emotional obstacles to using aids optimally. Acknowledging patients' losses and honoring their grief can set the stage for sharing the hopeful news: from Wal-Mart canes to high-tech orthotics, aids offer a way to take ownership of their life and function as normally as possible.

Monday, August 6, 2018

Soliloquy on a Life-and-Death Decision

​Begin hospice? Or try a promising-but-unproven therapy? It's an agonizing decision for patients who have no standard options and are ineligible for trials. How you present those options plays a major role in their ability to make informed decisions in keeping with their values. The fictional soliloquy below, based on a true story, illustrates how your words may guide and support patients throughout their lonely journey of decision-making.

SETTING: Dusk. A middle-aged patient sits at his kitchen table all alone, staring at the spiral notebook with notes from his doctor visit earlier that day. A few wadded tissues are off to the side. He hears his doctor's voice in his head.

DR. ATZ (voiceover)

Power lies in choosing how we play the hand life deals us. You can choose what you do now.

PATIENT

How do I make this overwhelming decision? Impossible! (He sets down the notebook and looks out the window at the setting sun.)

The drug is my last hope—if it really is a hope. It's too new to know if it helps or hurts patients like me. I don't wanna be a guinea pig. But if I don't take it…we're talking hospice. I'm not ready to die; I guess I have to take the drug.

The drug is promising—not like trying some kooky cancer cure. And it won't be like taking chemo, because side effects are mild in most people. (grunt) Most people. That treatment has made some patients sick…sick enough to die.

Oh, God. (He clasps his head in his hands.)

How am I supposed to figure out what to do? More than I don't want hospice, I don't want to take the drug, get sick, and die anyway. There must be something better….

DR. ATZ (voiceover)

I wish we had something better to offer.

PATIENT

Dr. Atz told me to focus on making the best decision. I've made difficult decisions before. She said this is just one more decision. Nuh uh, this is not like any decision I've ever made. Before today, we never mentioned hospice. I…(sniff)…want…(sniff) to live. (sobs, briefly) I'm just not ready…to give up…to stop fighting.

She tried to say there are different ways to fight cancer. Sometimes patients fight by doing treatment. Other times patients fight by optimizing quality of life. Both sound like losing ways for me to fight my cancer. I've never felt so powerless. (He looks at his spiral notebook.)

"Power lies in choosing how we play the hand life deals us." Dr. Atz is right: I have the power to choose. I can weigh the pros and cons of each option, giving extra weight to things that matter most to me.

(He gets up to flick on the wall light switch. He sits back down, turns to a blank page, draws a vertical line down the center, and writes at the top, "drug" on one side and "hospice" on the other.)

First, the pros of taking the drug. If it works, I get my life back. (Under the "drug" column he jots down, "It may work.")

Dr. Atz wouldn't have mentioned the drug if she didn't have hope it might work. Right? The man in the magazine article went from death's door to clear scans and good health. That could be me. (He smiles weakly for a moment while adding stars next to, "It may work.")

Besides, if I go for the drug I won't have to think about the "H" word (hospice), let alone have the "H" discussion at home, with those sad faces that make me feel awful, like I let everyone down. (Under "drug," he scribbles, "No 'H' talk.")

Dr. Atz warned me talking about hospice is sad, even for patients confident it's their best choice. She emphatically insisted hospice is about living and encouraged me to make a list of things I'd do if I stopped treatments. Wow, it's hard to remember life without treatment. (faint smile) So many things I'd love to do! (Under "hospice," patient starts writing a list of activities he's postponed or abandoned because of treatment. He freezes mid-word. His smile fades.)

I'd rather feel crummy and go to the clinic every day, if treatment gave me a chance to survive. That's the kicker, eh? Nobody knows if the drug increases my chance of survival. Oh, I hate the uncertainty.

Although…uncertainty means there's hope, which means uncertainty is good. Ah, maybe now I know what to do. I'm pretty sure I'd rather live with the uncertainty of treatment than live with the certainty of hospice. The minute I start hospice, I'm dying.

DR. ATZ (voiceover)

(firmly) You are not dying now, whatever you decide about treatment.

PATIENT

Fine. I'm not dying today. I'm dying within 6 months. That's the official life expectancy in hospice. How can I enjoy life while expecting to die? I can't imagine living without some hope of surviving. (He flips back to his doctor-visit notes)

DR. ATZ (voiceover)

You can expect one thing and hope for another.

PATIENT

I always thought hospice patients were hopeless. Then she told me stories of patients in hospice who prepared their funerals down to the readings and songs yet kept hoping to recover. Expecting the likely outcome while hoping for the best, they thumbed their nose at cancer by enjoying life in ways they couldn't while in treatment.

Most of those patients ended up dying. But not all. One of her patients recovered, unexpectedly and inexplicably. A few patients stopped hospice to enter newly opened clinical trials. Many lived longer than expected, surely longer than had they continued treatment that didn't work.

DR. ATZ (voiceover)

In hospice, the only hope patients must let go is hope that treatment can help their cancer.

PATIENT

I get it. There's always hope. Good to know. (sigh) Now I'm back at square one.

Maybe I should try the "regret" exercise Dr. Atz mentioned. It's designed to stir emotions that might help me decide. I'm supposed to think about each option separately, imagining how I'd feel if I had the worst outcome and if I had the most likely outcome.

Which worst outcome would make me regret my choice more: Getting sick from the drug without it helping my cancer or getting sick from my cancer in hospice too quickly for any quality time? Hmmm….

Lemme try that exercise again, only this time looking at the most likely outcomes. After all, according to statistics, the most likely outcome is the most likely. In hospice, the likely outcome is dying. In treatment, the likely outcome is, ugh, dying. At the end in hospice, would I regret not trying the drug? Hmmm…. At the end in treatment, would I regret the time I'd spent at the cancer clinic or being sick from treatment? Hmmm….

(His eye catches the large refrigerator magnet with block letters that say "Triumph over cancer is measured by how I live, not how long.")

Since our first meeting, Dr. Atz kept telling me her goal was to help me live my best life every step of the way. Whatever my test results, she always reminded me clear scans were not the goal…they were only a means to our goal. Cancer made me realize that "now" is all any of us really has—sick or healthy...that every day is a gift. How do I want to use this gift of today? Clearly, there's no right answer…or easy answer.

Dr. Atz believes there is a best answer for me—and I'm the only person who can find it. The last thing she said before I left her office was to listen to my hopes, because "Where there is hope, there is life."

Maybe the key to solving my dilemma is figuring out which hopes can help me live my best life now. Will I find the most meaning and most happiness by holding on to any sliver of hope of treatment? Or by letting go of that hope and by making quality of life my number one hope?

I wish I could have both hopes. I can't. It comes down to deciding which hope takes priority, which one I hope for more. (long pause)

Given my chances with each option, and the pros and cons of each option, I think I know. As much as I want to stop thinking about this and be done, I'll wait at least a day before doing anything. Then I'll call Dr. Atz's office with my decision.

This view from the other side of the stethoscope doesn't reveal what the patient decided. Without knowing his top-priority hope, it's impossible to deduce from the soliloquy. That scripted ambiguity highlights that the best decision is not determined by statistics or medical information, but by patients' ability to weigh the pros and cons of each option in the context of their values.

The best you can do in the face of uncertainty is to facilitate your patients' efforts to choose. By sharing insights and decision-making tips along with medical information, you help them process the information and reflect on their values throughout the decision-making. Then, whatever the outcome, everyone can take comfort in knowing patients took the best path for them, a path lined with the hope that enabled them to live as well as possible.