The Hypothetical “If”

The patient was clearly dying but no one acknowledged this. Instead, the oncologist proceeded to tell the patient’s children that IF the patient regained her strength, she might become a candidate for chemotherapy. At this time, given the patient’s weak state, the risks of an aggressive treatment such as chemotherapy would likely outweigh the benefits.

This was clear to me. The patient barely opened her eyes during the encounter, relying on her son who had traveled from out of state, and on her daughter- now her 24/7 caregiver- to provide any details related to her cancer diagnosis received just a few months prior.

“How likely is it the patient will get better?” I asked my supervisor, who was the oncologist on the case, when we were outside the patient room. She replied, “Not likely. Metastatic pancreatic cancer is aggressive. My estimate is that she probably has a few months left to live.”

I wondered why we hadn’t communicated this to the patient and to her children. Halfway through my hospice and palliative medicine fellowship, I had already heard of the “hypothetical IF” often posed by medical providers, including oncologists.

IF she gets better, then we MIGHT… consider treatment for the cancer. -

But, what IF we don’t expect the patient to get better? Is it cruel to propose hypothetical scenarios? Is this merely extending false hope?

The oncologist added, “What’s tough about this case is that the patient hasn’t even received treatment. We have to give her a chance.” For months, the patient had been in and out of the hospital due to complications related to her cancer and this had delayed the start of her cancer-directed treatment.

I could appreciate the desire to give someone a chance. After all, the children, who were the only ones capable of communicating with us now, were clear that their goals were to pursue cancer-directed treatment. They were hopeful to cure the cancer. They did not want to discuss hospice when this was asked. They had specifically traveled to our clinic to be considered for the most advanced cancer treatments. But was this really in the best interest of the patient?

I thought of the ethical principle referenced in our Hippocratic oath. Nonmaleficence: do no harm. The patient was already spending most of her day in bed due to severe weakness. In our clinic, she had to be transported on a wheelchair from the waiting area to the exam room. She had poor appetite and looked frail.

I wondered what the family hoped for by seeking additional treatment. Were they hoping the patient would recover her previous level of functioning before she was diagnosed with cancer?

Though I specifically sought this clinical elective to learn about cancer trajectories and prognoses, it was already clear to me that this was improbable. Our patient would never function as before. She was struggling to keep her eyes open and breathe. It did not seem to me she was living. At best, chemotherapy might give her more months, but these months would likely be limited by her poor quality of life. Her weakness, fatigue, and anorexia would all likely get worse with chemotherapy.

Would this be acceptable to her?

I was on my oncology elective, but I thought back to my psychiatry and palliative care training thus far, and the importance of understanding the patient in front of me, wholeheartedly and holistically.

It seems to me that the question we should’ve been asking the patient as her providers is- What IF we focus on what’s most important to you? What would that look like?

We, medical professionals, spend over a decade of training learning about illness and treatments but our job as healers is to individualize our recommendations to the person in front of us by seeking to understand them as persons- not patients with diagnoses and treatments- people with values and purpose.

What IF instead we start by asking, “What makes your life meaningful, and how can I support that?”

Written by Sharely Fred-Torres, Fellow in Hospice and Palliative Medicine