Sometimes I get so frustrated when an oncologist continues to recommend chemotherapy at a point in life when it is obvious that the patient is dying.
And I know I am not alone. Other nurses, particularly those who are at the bedside, experience similar frustration. I had a nurse recently tell me that she knew that last dose of chemo would kill the patient. We value what oncologists do -- the knowledge and the skill -- but we sometimes wonder why they wait so long to refer patients to hospice care. As nurses, we feel at times that patients are being treated to death.
When we hear, "We have to give them a chance," we think, "A chance for what? To die from side effects of chemo? How is that better?" The frustration can be almost unbearable.
There are times when a patient clearly is having an acute illness, and it is obvious that, despite their critical state, chemotherapy will help. But then there are times when patients have metastatic disease with a best-case-scenario life expectancy of six months. We watch the patients deteriorate. We listen to the doctor tell them that they are in the middle of their nadir, and that it's not the time to decide to stop treatment. And we think, "If not now, when?"
Nurses have the benefit of seeing a lot more from a patient perspective, but we also have the moral dilemma of administering treatment that often makes the person suffer more. This contributes to compassion fatigue (which we've covered before).
However, one session at the recent AAHPM conference talked about the oncologist's perspective. This made me rethink. Sometimes in my frustration, I am casting the oncologist in the role of the bad guy, and this just isn't fair.
With the advances in treatments, oncologists are seeing patients live longer, and they may have formed emotional bonds with patients they have successfully treated multiple times over many years. Oncologists know very well the physical toxicities of chemotherapy, but they may not realize the nonphysical treatment burdens, such as being too tired to enjoy time with one's children at the end of life.
The oncologist may overestimate the prognosis of the patient. They are trained to treat disease, so when appropriate treatment options are available, they recommend them. That's why patients go to them. They may not want to deprive a patient of hope or the opportunity to pursue the standard of care, or maybe they just don't want to make the patient cry.
Oncologists may identify with a young patient with a family, thinking to themselves, "I have a child that age. I'd want every chance to live!" They may view chemotherapy as part of palliation of symptoms, which may be true in some cases.
Because nurses provide a lot of emotional care during the end of life process, we become comfortable with supporting end of life care and having those "awkward" conversations with patients. Doctors might give the bad news, but they aren't often the ones who witness the outcomes at the bedside. Nurses help patients accomplish "good deaths." Though we find it emotionally trying, we also learn to talk to patients to help them make end of life decisions and accept when treatment is not the best option. I think we have a comfort level with death and dying that physicians do not, because we are on the front lines.
The next time an oncologist says something that goes against my grain as a nurse, I will try to remember that oncologists are people, too. They have feelings, and they aren't trying to prolong life at all costs. They have a different perspective than I do, but we are both trying to care for the patient. Let's not forget that we are all experiencing a kind of grief. We all went to school thinking we would save lives, and if we're lucky, we might all have the opportunity to save a life. But maybe both medical school and nursing school should teach us that we will definitely all play a part in death.