Cancer: How does a doctor deliver a fatal diagnosis??
Professor Dr. med. Ralph Naumann (left)treats many cancer patients. Francesco Formiglio is also one of his patients. Photo:Jennifer Wirth
Siegen. Oncology chief physician Prof. Dr. Naumann from the St. St. Mary’s Hospital tells of work with people with severe cancer.
Professor Dr. med. Ralph Naumann is chief physician of the clinic for medical oncology and palliative medicine at St. St. Mary’s Hospital and deals with people suffering from cancer on a daily basis. He gives an insight into his work and how he deals with the subject of death.
"When cancer is diagnosed, we distinguish between curative and palliative treatment," says Naumann. Curative methods aim at a cure: "I can cure many people." Palliative treatment is about diseases that cannot be cured. "There’s a huge bouquet of options there. There are people who nevertheless live for many years, and people for whom the end is very near."But the head physician doesn’t want to hear sentences like "I can’t do anything more for you". "It’s a gross error in communication. I can always do something for the patient. I can alleviate the symptoms."
How does a doctor deliver a terminal diagnosis? "I address it when I know the disease is not curable," Naumann says. It is important to take the time to pronounce the word "cancer" in a concrete way. "I then look the patient in the eye and feel that the message has been received. I’m honest, but I don’t want to hurt anyone." The uncertainty is usually worse than the actual diagnosis, he said. However, the chief physician does not use the word "die". "I then say that the disease limits life."The expert does not give an estimate of how long a person can live with a fatal diagnosis. "I just don’t know that."He criticizes that many colleagues go too far out on a limb and give concrete time frames. "Such a statement is never true."
It is often the case, he says, that patients already have a sense of their situation. "I’m expected to be honest. I would never say that someone has a chance if there is none." Naumann clarifies if there is a chance of a cure. If so, it also says whether the cancer is curable or "highly likely to be curable". Many of the 300 or so types of cancer can be treated well, he said. "For example, chronic leukemia is curable with pills."This provides hope. Once, the chief medical officer says, he even experienced a medical miracle. A patient with lung cancer and many metastases had experienced a so-called spontaneous remission, i.e. a recovery. For inexplicable reasons, the malignant cells have regressed. "However, this is very, very rare."
There are also medical specialists who arouse false optimism. Just recently, a doctor sent a 27-year-old woman with a brain tumor to him with the promise that "there’s still something there," and that there would be no need for surgery. "I have seen the pictures and knew immediately: There one cannot operate."The woman will die of her cancer.
Many people get immunotherapy drugs instead of chemo. These would have other side effects – hair loss, for example, is not one of them. This takes the pressure of suffering away from the sick. They are very ill, but not everyone addresses them directly. "You can’t tell some people have the disease. There are tumors that do not show symptoms until very late," says Naumann. Let every case be different. Sometimes an operation is best, in other people medication or radiation.
Naumann says many people have two major fears of death: dying alone or dying in fear with pain. "Nobody has to die alone." The palliative care network, hospices or the family help with this. "People with lung cancer in particular are afraid of suffocating or dying in pain," Naumann says. "I can promise them I will do everything I can to make sure they don’t have to suffer."By administering medication, he could alleviate this fear. "It’s called palliative sedation."Breathing is made easier and patients fall asleep – they do not realize that they are dying. It concerns indirect euthanasia, which is permitted in Germany. Passive help by turning off life-support machines is also allowed.
At the last moment
Quite often, according to Naumann, dying in a clinic is more pleasant than somewhere else. Here doctors could better relieve the pain and intervene. Instead, the chief physician would like to see more single rooms. From experience, the doctor can estimate when a life comes to an end: "The contour on the skull becomes clearer. There may be pauses in breathing or irregular breathing . until the patients finally stop breathing."The voice also usually becomes quieter. Also give it humans, who die over days or weeks. "We know then that they can still hear for a long time. We advise relatives to be there and talk to them."
It is not uncommon for patients to hold out until all relatives have been at the bedside. But, he says, there are also patients who seem to deliberately wait for the moment when relatives leave the room for a moment. "We have the feeling that some patients want to escape." Scientifically this is not explainable.