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Grace Notes is a series of essays by Sound Medicine contributor Dr. Larry Cripe, an oncologist specializing in palliative care at Indiana University Hospital in Indianapolis. Dr. Cripe reflects on how we might make the experience of dying more livable and meaningful, before, during and after a person passes.

Treating Terminal Cancer Means Not 'Giving Up' But Choosing Different Goals

In a few hours, my patient Dawn would leave the hospital after a stay of nearly six weeks. I wouldn't be surprised when her mother called me a week later to tell me that Dawn died at home surrounded by her friends. But for the moment the resident physicians and I were planning her discharge. And the senior resident asked me,"Why are we giving up?"

This is a common question in my conversations with physicians in training and with patients. "How did you know it was time to give up -- are there not other things we can offer?" a resident might ask after I've recommended hospice care. They hear the language in my conversations with patients and family. Patients frequently assure me they are not inclined to give up. A family member may ask "Are we giving up too soon? Have we done enough?" But outside of Dawn's hospital room as I glanced at the sagging shoulders and distracted shuffling of Dawn's interns, I became aware that the plans -- no further chemotherapy, no antibiotics, no transfusions, and no intravenous hydration -- could only feel like giving up. And I felt more deeply than ever before their struggles to understand why it's not. Yet I had no answer for them.

Instead of asking "Are we giving up too soon?" the better question to ask might be: What do we provide instead when we accept that death is imminent and move away from aggressive medical care? I believe the answer is ourselves: We accept the responsibility to remain deeply aware of the patient's suffering without recourse to futile medical care. In a word, we offer compassion.

There are two measures of compassion most relevant. I am drawn to the metaphor of illness as a journey. I see myself as being trusted to guide the ill person across an unfamiliar and threatening territory. As a physician trained to modify the future for the better I, like many people, imagine each journey as moving towards the desired destination of restored health. Thus, one measure of compassion is our ingenuity in the treatment of disease. In a sense the desire to relieve suffering through the prescription of potential remedies makes the journey we share with a seriously ill person a journey with compassion. 

But we physicians should expect more of ourselves. The more demanding measure of compassion is the trustworthiness to initiate and engage in earnest conversations about the end of life. A journey of compassion demands that we take the time, invest the energy, and have the vulnerability to imagine the different possibilities and opportunities when death is imminent and inevitable. The night before Dawn left the hospital, we shared a different conversation. I told her I could not imagine that she would ever feel well enough -- be well enough -- to receive further anti-leukemia therapy. I shared with her my belief that she would die whether she received anti-leukemia therapy or not. Haltingly, I tried to explain the future I imagined: more physical distress with the prolonged hospitalization and continued need for intensive supportive care and our greater sorrow and regret. I acknowledged the uncertainty. I did not know -- and still do not -- whether she would suffer less with the care she received or whether she would have lived longer with aggressive treatment. 

In the end, reflecting on my failure to answer the resident's question, I discovered that there are times when I need to be less of a physician in order to be more of one. Today I would assure the resident we were not giving up on Dawn. We were giving up our expertise and skills in the treatment of disease. We were accepting the most sacred commitment: to remain present, to try to relieve suffering, not through remedy but by imagining different goals, achievable goals, as life is ending.

Larry Cripe, MD is a hematologist and oncologist specializing in palliative care at Indiana University Hospital in Indianapolis. This essay originally aired on Sound Medicine on March 22, 2009 as part of the "Grace Notes" series.