Reacting to Bad News: Forget and Smile?

Christina Georgina Rossetti, one of the most important women poets writing in nineteenth-century England wrote:“Better by far you should forget and smile/Than that you should remember and be sad” But is being sad always something to avoid? Read this excerpt from a blogger’s current life experience with cancer.

Somehow we got this idea, and Christians are the absolute worst about this, that being sad or angry is a bad thing.

Whenever I post something to the effect that "Cancer is bumming me out today," I get a bunch of emails and comments to the effect of "Buck, up, little camper - God will provide! God loves you! Be happy! I'll pray that you stop being sad!"

Well, sad is an appropriate response to cancer sometimes. My doctors are all saying I have a great, healthy, positive attitude about my disease, but they are also aware that I have a potentially fatal illness that has spread far and rapidly and that sometimes I'll be less-than-joyous about that.

Sad is ok. Feeling the way you feel is ok, until it becomes destructive. I'd worry about me if I went around all day with a goofy grin and never looked at the negative consequences of cancer.

I say all that to say this: I'm sad right now.

I agree that a cancer patient, such as the blogger above, being sad is an emotion that can represent the patient’s realistic reappraisal of their life. Their goals, which they have set in the past, now must be reconsidered in view of the diagnosis and prognosis. The role of the physicians in treating their cancer patients who demonstrate sadness is to understand what the patient has concluded on reappraisal of their life and, if unrealistic from the known clinical facts, educate the patient about this. However, if realistic, allow the patient an opportunity to ventilate about the consequences of the diagnosis and express his or her feelings. Perhaps in this way the patient, with emotional support by the physician, can set and accept more limited goals, which will provide more comfort for the patient in their remaining life. In my view, prescribing “Forgetting and smiling” is an unreasonable and unwise approach to therapy. ..Maurice.

Doctor,Doctor: Just How Long is there To Go?

From the chorus of “Doctor,Doctor” by Who:

Do you think it's time that I made out my will?

I'll leave everything to you to pay my bill

Just how long is there to go

Please tell me I want to know

But on second thoughts don't tell me, I'm too ill.

“Just how long is there to go”(“How much time do I have to live?”) is a question that is often posed by patients when they first learn that they have a potentially terminal illness. And it is often one of the most difficult questions for a physician to answer. We discuss this issue with the medical students in their first year.



What is the answer? Do doctors really know the answer? No. Doctors really don’t know for the specific patients who question them. There may be some statistical information about the disease in the literature and there is the physician’s own clinical experience with the disease but is that sufficient to yield an answer to the distraught patient? Not really. If so, then on what basis should the physician reply with anything beyond “I don’t know”. Students are taught to ask the patient for the reason for the question. The patient’s reply often provides a host of issues for which the physician can get insight into the patient’s psycho-social life and may be able to provide emotional or other support even without giving a definitive answer.



It is the physician who promptly replies to the patient’s question with a short, arbitrary answer and without further questioning or discussion who will be long remembered, but not in a helpful sense, by the patient who has also long survived the “6 months” death sentence.



Students are taught to be certain that the patient wants to talk about the prognosis in quantitative terms since “on second thoughts, don’t tell me”. If it is clear the patient wants to talk about their remaining lifespan, the only thing the physician can do is describe the data in the literature to the patient and explain the uncertainty of the statistics as applied to the individual patient.



It is a difficult experience for a doctor to give the patient “bad news” and it is most difficult to find answers to all the questions that follow. I would be most interested to read from other physicians who visit my blog how they approach the answer to the question “Just how long is there to go?”

Feather in Our Physician's Cap but a Knife in the Patient's Heart.

This story has been published on various blogs including The Onion. If it is a true story (or even if it was a madeup scenario) it does represent a behavior that could be common to most all physicians. But it also provides a basis for caution.

ROCHESTER, MN—Dr. Erich Stellbrach, a general practitioner at the Mayo Clinic, could barely contain his exhilaration Monday upon discovering that patient Oliver Patterson, 54, has the extremely rare degenerative nerve disease Gertsmann-Straussler-Scheinker syndrome. "Mr. Patterson, I'm so sorry to tell you this, but you have—you're not going to believe it—spinocerebellar ataxia!" Stellbrach said, waving an x-ray of Patterson's spinal cord. "It afflicts only one in 2.9 million people!" Stellbrach recommended Patterson begin aggressive treatment to mitigate his impending brain dysfunction and onset of dementia, and made the patient promise to remain in his care.

Physicians are humans. We work hard. There is pleasure in our work by watching a patient recover from an illness. Unless we are a surgeon, we think and hope we had something to do with the recovery but often it is the patient's own body that heals itself. And we know that too. We often look forward to making a discovery in a patient that others have missed, especially if something constructive can be done for the patient. Finding the patient has a rare disorder is a thrill and something to be remembered thoughout our careers. But for the patient, the diagnosis may be no thrill that brings pleasantness or happiness, in fact it may bring anxiety and concern. To the patient "rare" means very unusual, that it hasn't been carefully studied, that noone knows anything about the cause or outcome and there hasn't been enough cases for a treatment to be devised.



The caution: What is a feather in our physician's cap can be a knife in the patient's heart. As physicians, in this moment of glory, we must contain our internal exuberance and remain aware what we say or do in the patient's presence. Our duty is to our patients, to serve them well and keep the professional glory to ourselves. ..Maurice.

Physician Autonomy vs Beneficence to the Patient and Plan B

When Dr Ward comes into the exam room Theresa explains to him that she was out at a party, had a few too many drinks, and ended up having unprotected sex with her boyfriend. She says she is worried about the possibility of being pregnant and wants the Plan B® pill.

“I don’t want to have a baby right now. I’m too young. I have to finish school,” she says. “And I don’t want to have to make a decision about an abortion. I want to just take this pill and move on.”

Dr Ward listens to Theresa’s concerns and then says, “I understand why you are here. I have always had a policy of not performing abortions, and I won't start now by prescribing the morning-after pill. You can make an appointment with me in a couple of weeks for a pregnancy test to find out if you are pregnant. If you really want the morning-after pill I can give you the card of a physician I know in Gardendale who will see you.”

“Gardendale?” Theresa says. “But Gardendale is 115 miles away. How will I get there without telling my parents why I am going? And how will I get there soon enough for the pill to work?”

I have written recently about Plan B and the anticipated decision by the FDA to allow over-the-counter (OTC) patient access (see postings of Jan 18 and Jan 23, 2005). The above scenario with two commentaries following, in the September 2004 issue of Virtual Mentor illuminates an important ethical issue that could be resolved by approval of OTC use. The issue involves the right of a physician not to engage in a treatment, which to the physician is morally wrong. This autonomous right of the physician has generally accepted ethical consensus. However, in certain situations, acting on this right may be non-beneficent for the patient by leading to the patient experiencing personally serious consequences. This conflict between the principle of professional autonomy and the professional duty to patient beneficence, in the case of Plan B could be mitigated by the FDA approval of the OTC procurement of this drug. ..Maurice.

Political Ethics: Leveling with the Public

The stem cell lines which are now available for federally supported research are contaminated with a protein from animals whose serum is used in the culture medium. This fact is confirmed in a study by researchers at the University of Califonia, San Diego and published yesterday in the online "Nature Medicine".



The article indicates that humans have antibodies against the foreign protein and when in contact cause the stem cells to die. The contamination cannot be removed. The researchers suggest that the only way to develop a non-contaminated line of stem cells is to start over with new lines and use of human sera for culture.



However, in a news release by Associated Press today:

"The White House is shrugging off the study's findings. Press Secretary Scott McClellan said the president is satisfied those existing lines are 'adequate for the basic research that needs to be done.'"



"McClellan said Bush knew about the contamination issue in 2001 but agreed with the view of top government scientists that it wouldn't prevent research into potential breakthrough disease cures."



I don't recall the president ever mentioning this contamination during his TV presentation to the public. I also can't find it in the White House press release at the time.



Could this be another example of the president not leveling with the U.S. public? Is national security at stake for the president not to disclose the contamination issue?

..Maurice.

Schiavo Case: Beyond Compassion, Beyond Ethics, Beyond Law

Here is today's story from AP News - from Tampa Bay Online: "WASHINGTON (AP) -- The Supreme Court refused on Monday [January 24, 2005] to step in and keep a severely brain-damaged woman hooked to a feeding tube, all but ending a long-running right-to-die battle pitting her husband against her parents.



It was the second time the Supreme Court dodged the politically charged case from Florida, where Republican Gov. Jeb Bush successfully lobbied the Legislature to pass a law to keep 41-year-old Terri Schiavo on life support.



The decision was criticized as 'judicial homicide' by Mrs. Schiavo's father, Robert Schindler, but applauded by her husband, Michael Schiavo, who contends his wife never wanted to be kept alive artificially."



I think this case has gone beyond consideration and compassion for the emotions of the family. It has gone beyond the legal decisions by the courts. It has gone beyond all ethical principles. The behavior of the family, after all the legal and ethical decisions were made to allow patient autonomy through the substituted judgment of a legal surrogate, the husband, appears to be solely in the family's own self-interest. And this behavior is wrong. Hopefully, with today's decision of the Supreme Court, the appropriate. ethical and legal conclusion of the case is soon to occur. ..Maurice.

Why the FDA Delay in Plan B Decision-Making? Politics?

From Reuters AlertNet - FDA delays nonprescription morning-after pill rule: "WASHINGTON, Jan 21 (Reuters) - U.S. regulators on Friday delayed a decision on whether to approve over-the-counter sales of a Barr Pharmaceuticals 'morning-after pill' to prevent pregnancy, prompting a lawsuit from a women's rights group.



Barr said it was optimistic the Food and Drug Administration ultimately would grant its request to sell the product, called Plan B, without a prescription to women and girls age 16 and older.



The FDA said it would complete its review 'in the near future,' according to a statement from Barr."



Barr had earlier agreed with FDA request to require a physician's prescription for those under age 16. It is worrisome that this delay in FDA's decision may have its basis more on politics rather than science. ..Maurice.