Keys to communicating with advanced cancer patients. When is the best time to begin this discussion?

FAQ Library published on December 7, 2016
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Eduardo Bruera, MD
F.T. McGraw Chair in the Treatment of Cancer
Chair, Department of Palliative Care and Rehabilitation Medicine
Division of Cancer Medicine
The University of Texas MD Anderson Cancer Center
Houston, Texas
Keys to communicating with advanced cancer patients. When is the best time to begin this discussion?

Welcome to Partners in Pancreatic Cancer. My name is Eduardo Bruera, and I am the Chair of the Department of Palliative Care, Rehabilitation, and Integrative Medicine at the University of Texas MD Anderson Cancer Center in Houston, Texas. My question today focuses on the keys to communicating with patients who have advanced cancer, and understanding when the best time is to begin this discussion.

We know that many cancers, including pancreatic cancer, will often advance soon after diagnosis. It is therefore very important to start communicating with patients about their prognosis, their diagnosis, and what they may anticipate as soon as possible in the trajectory of illness. It’s well known that patients frequently do not ask some of the very important questions that they have in mind. Therefore, helping them with this communication can be very useful, such as by giving them prompt sheets in the waiting room about questions they may have. One of the problems we often see is that, in general, there is a trend to say, we’ll have a conversation about prognosis, about end of life care, and about advanced care planning, once we know how the treatment is working. Unfortunately, it’s often clear, by that time, that the treatment is not going very well, that problems have already occurred and the patient’s care is now very complex; sometimes at this point, the patient may even be unable to participate in the conversations. It is therefore very important to have those discussions about prognosis with the patient as early as possible.

Now, of course, many health care professionals are worried about decreasing hope in our patients and families. At MD Anderson, we’ve developed a communication approach that is designed specifically to improve these conversations, and to support a better understanding of these challenging issues among our patients. Many times, as clinicians, we talk about the goals of care. This is complex because if I’m a patient with an incurable cancer and you ask me what my goals of care are for my disease, I might say, “Well, doctor, make my cancer go away” or “Turn my cancer into diabetes and allow me to live for another 30 years.” Especially with incurable cancers, neither of these may be possible. So, at MD Anderson, we focus these conversations on what we call the “goals of car”, so that we can emphasize how the goals of care in cancer really parallel the goals you have when you buy a car. Now, what does this mean?

In Texas, most people own cars, and when you buy a car, you have the best hope and expectations for the car you purchase. You need it to go to work, and you want to take it for vacations – you want to use it. Everyone understands the fundamental rules of car safety, however, so while you’re using your car every day, you buy insurance, you always wear a seatbelt and when you leave it parked at the shopping mall, you lock it. You don’t do these things because you’re pessimistic or depressive, or because you believe your car is going to be stolen, but you do understand that people do have car accidents, and their cars could be stolen. By having insurance, by wearing your seatbelt, by locking your car, you improve your quality of life as it pertains to your car.

Similarly, when we make a diagnosis of cancer, we encourage our patients and our health care professionals to take the same mental approach as we take with our car. Just as we wear a seatbelt to minimize injury in case we do get into an accident, we need to prepare ourselves for all eventualities, in case they should occur. So, while we have the highest expectations for the success of our prescribed cancer treatment, whether it be surgery, radiation therapy, chemotherapy, targeted therapy, and even experimental therapies, it is still very important to have a conversation about what we may experience. What happens if I’m not able to drive myself and I need somebody to help me? What happens if I’m not able to climb the stairs to the bedroom and I need some help – who would live with me if I have difficulty getting out of bed? And finally, what would I like to have done if the end of the life happens? Just because you wear your seatbelt, you are not guaranteeing you’ll have a car accident, and similarly, we can have these conversations without guaranteeing that the patient will have to face those situations.

By approaching these topics with this perspective, we can have these conversations without changing our expectation of success for a treatment. This approach helps us to have these discussions early in the treatment process, and often results in a different type and tenor of conversation, as compared to having these discussions after the treatment has failed. We tell our patients that it isn’t going to be easy to get insurance after you crash your car or after it has been stolen, and similarly, it is very, very important to have these conversations when we really don’t need them, so that the topics have already received due consideration at the moment it becomes necessary.

I would like to thank you for viewing this activity. For additional resources, please be sure to view the other educational activities on PartnersinPancreaticCancer.com. Thank you very much.

Download the patient prompt sheet to use in your practice:
Question Prompt Sheet

Last modified: February 17, 2017
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