“If”—not “When”
2006; Wolters Kluwer; Volume: 28; Issue: 13 Linguagem: Inglês
10.1097/01.cot.0000295055.12898.01
ISSN1548-4688
Autores ResumoDr. Betty Katz hunches over the nursing station, writing orders. The clatter of a chart landing on a nearby desk catches her attention. Out of the corner of her eye, she watches a colleague fumbling with his stethoscope while slipping his cell phone in his pocket. “Hello, Dr. Solor.” Dr. Katz's distinctively dusky voice invites conversation, “And thank you for your lovely update notes on our mutual patient, Jeff. I guess you'll be seeing him soon for his first post-treatment follow-up?” The young oncologist sits down and smiles timidly, still daunted by her wealth of experience and insights. “This afternoon, actually.” “Could I trouble you for a quick update? He's on my schedule for Friday for his routine annual exam, and it'll help me if I know what he's been told.”Figure: Wendy S. Harpham, MD is an internist, cancer survivor, award-winning author, and mother of three. Her books include “Diagnosis: Cancer,” “After Cancer,” “When a Parent has Cancer,” (selected as the #1 Consumer Health Book of 2005 by American Journal of Nursing), and, most recently, “Happiness in a Storm.” She lectures to professional and lay audiences on a wide range of issues centering around “Healthy Survivorship,” including recovery and late effects after cancer, raising children when a parent has cancer, clinical trials, and finding happiness in hard times. Further information about Dr. Harpham and her work is available at www.wendyharpham.com.“Absolutely. He's had a nice response: a complete remission. Unfortunately, when his cancer comes back, it'll be aggressive. We won't be able to do much.” “If,” Dr. Katz says, crisply. “'If?” “If Jeff's cancer recurs.” She continues without a trace of sarcasm, “If he doesn't first get killed by a Mack track on his way to your office.” Dr. Solor grimaces. “I have to be honest with him.” At every visit, Jeff says, “Doc, tell me the truth. And don't sugarcoat!” Assuming he won't get hit by a Mack truck, I'll lay out the situation, not only out of professional obligation but also out of respect for him. “After all, Jeff is a scientist.” Dr. Katz's expression remains unreadable. “Jeff's cancer will recur,” he repeats, gently, as if unsure he was heard. “And when it does—this type always does—it's bad.” “Always? Forgive my contrariness, Dr. Solor, but someone somewhere survived his type of cancer.” “So?” “So, if—not when.” “With all due respect, Dr. Katz, aren't you suggesting I encourage Jeff to hang his hope on something that rarely ever happens? Aren't you asking me to give him false hope?” “False hope is the belief in something that is impossible. It may be unlikely that Jeff will have a long remission or that a new treatment will be discovered in time, but it is possible.” “But the chances…” “…are infinitesimally small. Believe me, I know.” Dr. Katz dabs at the moistness in her eyes with the back of her wrist. “So does Jeff. I've known him since he was a graduate student. As you said, Jeff is a scientist.” “That's why he expects me to be straight—scientific—about his current prognosis.” “Prognosis, not prediction. Nobody's looking to you for certainty.” “Then, what?” “The likely outcome. And what can be done, if anything.” She leans her face in closer to his, “You have some hope, don't you?” then immediately retracts both her question and her body. “Wait!” she protests, her forearm instantly between their faces, arthritic fingers pointing up and palm facing forward like a policeman's signal to stop. “Don't answer that.” Lowering her hand to her lap, she asks, “Do you remember how, after Jeff's diagnosis, he was immobilized with morbid thoughts? You recommended a support group?” He nods cautiously. “It saved him. Taught him how to find hope and to laugh again.” If you have two more minutes, I have a quick story from a time before support groups, before pink ribbons and yellow bracelets, when the only “survivors” were relatives who lived on after loved ones died. “I'd be honored.” “Thirty-odd years ago, I'd just passed my medicine boards when I developed belly pain due to a complex ovarian cyst.” The night after my surgery, my OB sat on my hospital bed and told me, “I got it all,” but a tiny spot on my liver made it Stage Four, and the likelihood of recurrence—aggressive and unresponsive—was high. I had two little kids at home, just like our patient, Jeff. My doctor then administered the medicine that helped me through the rest of that horrific day, and the day after that, and the next day after that. He said, “Betty, you are doing well now. If your cancer recurs…” She pauses before concluding, “Whatever you might be feeling yourself, leave space for Jeff to decide how much hope he wants to have.” Later that afternoon, Dr. Solor enters the exam room where Jeff sits expectantly. After performing a physical exam and checking the lab results, he shares the good news. As predicted, Jeff asks, “Okay Doc, what's the prognosis? Tell me the truth. And don't sugarcoat!” Dr. Solor straightens his tie and clears his throat. “The usual scenario for patients in remission from this type of cancer is that the cancer recurs, aggressive and hard to treat.” Jeff remains motionless. “But rare, unexpected, long remissions can happen. And, new treatments are coming down the pike.” Jeff, you are doing well now. If your cancer recurs, we'll deal with it. For patients facing a high risk of recurrence, a physician's “When” prefaces a prediction, not a prognosis, and forces patients to choose: Either they live the rest of their days without hope, or they rail against the edict by nourishing hope against the odds and, in the process, losing some confidence in the doctor who's given up. A prediction of doom, like a terrible secret you wish you'd never been told, burdens patients with a sense of certainty that makes it far more difficult—and for some patients, impossible—to find joy. In contrast, a prognosis preceded by “If” introduces uncertainty. This hint of possibility encourages patients to strive for a balance of hope and acceptance that helps them work and play, laugh and love in the face of a fragile future. For patients to be free to find the balance that helps them live, the door must be left open for them to find hope.
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