Pessimism Is No Poison

Dee Jones is 35 years old, married, and the mother of three children, all younger than15 years of age. She had been healthy all of her life before she presented with a 2-week history of abdominal discomfort and anorexia. Evaluation revealed moderate jaundice, an enlarged liver, and abnormal liver function tests. An image of the abdomen showed a pancreatic mass and widespread metastatic disease to the liver. A liver biopsy confirmed a diagnosis of metastatic pancreatic carcinoma. She received first-line chemotherapy for pancreatic cancer and returned 6 weeks later for re-evaluation. She had evidence of disease progression, increasing pain, weight loss, and was bedridden more than 50% of her waking hours. A staff oncologist, accompanied by a first-year oncology fellow, visited with the patient. With the patient acknowledging that she wanted to hear prognostic information, the medical oncologist had a heart-to-heart discussion with the patient. The senior oncologist noted that survival is typically measured in weeks. They discussed treatment options ranging from additional chemotherapy to participation in an early-phase clinical trial. They talked about symptom management and hospice care. They agreed that no further cytotoxic chemotherapy would be used. The conversation was difficult for all: the patient and her husband cried and the oncologist was visibly moved. After leaving the room, the staff oncologist and fellow discussed the consultation. The fellow asked the oncologist why he was so pessimistic when talking with the patient. Why did he say things to make the patient and her husband cry? Shouldn’t he have given the patient more hope? Would it not have been better for the patient to hear this dire news in chunks over the course of several clinic visits? After all, the patient was so young she may just beat the odds.