The first reaction comes from the appreciation of the almost universally fatal nature of the high grade brain tumour.
But the management of the cancer patient is not a one-to-one affair. And the position of the cancer patient brings with it many other issues. Consider the following cases dealt with before:
- the 62 year old man with lung cancer who lives in the same town as his youngest son, but the son crosses the road when his father approaches. It is 3 days before Christmas and he is going home.
- the 11 year old girl with a brainstem glioma
- the 84 year old Macedonian grandmother with a duodenal cancer who raised several of her grandsons, one of whom is getting married in 6 weeks (about the same duration as her predicted survival!)
- the 58 year old woman who comes to clinics alone every time, and whose husband just wants her to get fixed and come home.
All of these cases present special challenges for the oncologist, GP and patient. For our patient, the difficulty is one of "it's not right!". So what is not right? It is not right that a parent has to bury a child, the children are supposed to do the burying.
On a personal note, in 1980 when my mother was dying of cancer, the day before she died she said to her mother "I'm dying Mum, please stay with me". My grandmother left the room, walked to our house, packed, called a taxi and went to the train station to wait for an interstate train to take her back home. You will think this harsh, cruel, mean, callous … and most of all incomprehensible.
But what you don't know is the background. You don't know about the sacrifices. You see, as a young mother and a foreigner she had stood on a bridge in a country that treated her like, and called her a 'dog', with 2 young starving children that she could not feed, and contemplated throwing her children into a cold river to drown. Thank heavens for me, she didn't! Later she would sit until 2-3am each morning embroidering tablecloths to make enough money to feed them. She would pick up dropped bread, kiss it and place it back on the plate. And now 70 years later, she was out of control again. What do you do when you are out of control?
So, what advice can you give this mother? As our colleagues here have demonstrated, high grade brain tumour is a diagnosis that few people escape. Modern surgery and radiotherapy has made little in-road into prognosis in the last 20 years, adjuvant chemotherapy has added a little time but little cure. With average survival for all patients after surgery being 17 weeks, and radiotherapy only doubling that time, there is little time for gently breaking bad news.
I defy anyone to demonstrate a "gentle" way to tell another human that they have 17-34 weeks left to live. There can be a lot of beating around the bush, but eventually you have to say "you have a brain cancer".
So how do you break the news, if not gently? There are recipes and guides, and they are at best helpful. What you need is humanity, whether you are the GP as in this case, or the ED doctor or the oncologist. Humanity. Honesty. Time. I don't really understand "empathy", I can not imagine what it is like to have my child with a brain cancer, or to have one myself. How do you get humanity? Well, you just have it! How do you get honesty? Well, you just keep it! How do you get time? You just have to make it!
