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Medical Writings |4 March 2003

Hope for the Best, and Prepare for the Worst

Anthony L. Back, MD; Robert M. Arnold, MD; Timothy E. Quill, MD

Article, Author, and Disclosure Information
Author, Article, and Disclosure Information
  • From Veterans Administration Puget Sound Health Care System, University of Washington, Seattle, Washington; University of Pittsburgh, Pittsburgh, Pennsylvania; University of Rochester, Rochester, New York.

    Acknowledgments: The authors thank Dr. Susan Block for her helpful suggestions about the role of ambivalence.

    Grant Support: Drs. Back and Arnold are Faculty Scholars of the Project on Death in America. Dr. Arnold was also supported by the Greenwall Foundation, Ladies Hospital Aid Society of Western Pennsylvania, and the LAS Trust Foundation.

    Requests for Single Reprints: Anthony Back, MD, Veterans Administration Puget Sound Health Care System, 1660 South Columbian Way S111, Seattle, WA 98108; e-mail, tonyback@u.washington.edu.

    Current Author Addresses: Dr. Back: Veterans Administration Puget Sound Health Care System, 1660 South Columbian Way S111, Seattle, WA 98108.

    Dr. Arnold: Section of Palliative Care and Medical Ethics, MUH 200 Lothrop Street 932, Pittsburgh, PA 15213.

    Dr. Quill: Palliative Care Program, University of Rochester School of Medicine, Box 601, 601 Elmwood Avenue, Rochester, NY 14642.


WORDS THAT MAKE A DIFFERENCE
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WORDS THAT MAKE A DIFFERENCE
Mr. J., a 40-year-old father of two young children, has metastatic nonsmall-cell lung cancer that has not responded to two different chemotherapy regimens. His physician, Dr. B., explains that the cancer is progressing. Mr. J. says, Isn't there something you can do? Please don't give up on me. Dr. B. pauses and says, Well, there is an experimental protocol we could try.
When faced with life-threatening illness, patients and physicians often feel that they must choose between hoping for disease remission and preparing for death. Mr. J. wants to fight the cancer in hope of living longer, and his physician is reluctant to discuss palliative care issues because she does not want to destroy his hope (1). Dr. B. knows that a patient in Mr. J.'s situation rarely benefits from third-line chemotherapy, and she also knows that by offering aggressive treatment she may be colluding with Mr. J. to avoid discussing the most likely prospectthat he is dying (2). Dr. B. is unsure how to proceed.
When patients and physicians discuss life-threatening illness by focusing exclusively on hope, they may miss important opportunities to improve pain and symptom management (3, 4), respond to underlying fears and concerns, explore life closure (5), and deepen the patientphysician relationship. The difficulty for physicians is acknowledging and supporting the patient's hopes while recognizing the severity of the patient's disease, thus offering an opportunity to discuss end-of-life concerns.
Hoping for a cure and preparing for potential...
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Back AL, Arnold RM, Quill TE. Hope for the Best, and Prepare for the Worst. Ann Intern Med. 2003;138:439–443. doi: 10.7326/0003-4819-138-5-200303040-00028

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Published: Ann Intern Med. 2003;138(5):439-443.

DOI: 10.7326/0003-4819-138-5-200303040-00028

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2003 American College of Physicians
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