The woman was terminally ill with advanced cancer, and the oncologist who had been treating her for three years thought the next step might be to deliver chemotherapy directly to her brain. It was a risky treatment that he knew would not, could not, help her.
When Dr. Diane E. Meier asked what he thought the futile therapy would accomplish, the oncologist replied, "I don't want Judy to think I'm abandoning her."
In a recent interview, Dr. Meier said, "Most physicians have no other strategies, no other arrows in their quiver beyond administering tests and treatments."
"To avoid feeling that they've abandoned their patients, doctors throw procedures at them," she said.
Dr. Meier, a renowned expert on palliative care at Mount Sinai Medical Center in New York, was the keynote speaker this month at the Buddhist Contemplative Care Symposium, organized by the New York Zen Center for Contemplative Care and the Garrison Institute. She described contemplative care as "the discipline of being present, of listening before acting."
"Counter to how the American medical system is structured, which pays for what gets done," she said, "its approach is, 'Don't just do something, stand there.' "
But the idea is not to do just that. Rather, she said, the goal is to "restore the patient to the center of the enterprise."
Under the Affordable Care Act, she said, unnecessary procedures may decline as more doctors are reimbursed for doing what is best for their patients over time, not just for administering tests and treatments. But more could be done if physicians were able to step away from the misperception that everything that can be done should be done.
Dr. Meier's question prompted Judy's oncologist to realize that what his patient needed most at the end of her life was not more chemotherapy, but for him to sit down with her, to promise to do his best to keep her comfortable and to be there for the rest of her days.
Patients and families may not realize it, but doctors who care for people with incurable illness, and especially the terminally ill, often suffer with their patients. Unable to cope with their own feelings of frustration, failure and helplessness, doctors may react with anger, abruptness and avoidance.
Visits may be reduced to a quick review of the medical chart, and phone calls may not be returned. Even though their doctors are still there, incurably ill patients may feel neglected and depressed, which can exacerbate illness and pain and even hasten death. Dr. Michael K. Kearney, a palliative care physician at Santa Barbara Cottage Hospital, told the Contemplative Care conference that doctors, especially those who care for terminally ill patients, are subject to two serious forms of occupational stress: burnout and compassion fatigue.
He described burnout as "the end stage of stresses between the individual and the work environment" that can result in emotional and physical exhaustion, a sense of detachment and a feeling of never being able to achieve one's professional goals.
He likened compassion fatigue to "secondary post-traumatic stress disorder, or vicarious traumatization — trauma suffered when someone close to you is suffering."
A doctor with compassion fatigue may avoid thoughts and feelings associated with a patient's misery, become irritable and easily angered, and face physical and emotional distress when reminded of work with the dying. Compassion fatigue can lead to burnout.
In one study of 18 oncologists, published in 2008 in The Journal of Palliative Medicine, those who saw their role as both biomedical and psychosocial found end-of-life care very satisfying. But those "who described a primarily biomedical role reported a more distant relationship with the patient, a sense of failure at not being able to alter the course of the disease and an absence of collegial support," the authors noted.
Healing the Healer
For doctors at risk of becoming overwhelmed by the stresses of their jobs, Dr. Kearney recommends adopting the time-honored Buddhist practice of "mindfulness meditation," which involves cultivating mental techniques for stress reduction that are native to all of us but practiced by too few. He likened meditation to "learning to breathe underwater, or finding sources of renewal within work itself."
To achieve it, a person sits quietly, paying attention to one's breathing and whenever a distracting thought intrudes, turning one's attention back to the sensation of breathing. This can help calm the mind and prepare it for a clearer perspective.
Dr. Kearney said this practice could help doctors "really pay attention and be tuned into their patients and what the patients are experiencing."
"Patients, in turn," he said, "experience a doctor who's not just focused on a medical agenda but who really listens to them."
He said mindfulness meditation helps doctors become more self-aware, empathetic and patient-focused, and to make fewer medical errors. It enables doctors to notice what is going on within themselves and to consider rational options instead of just reacting.
"It's like pressing an internal pause button," Dr. Kearney said. "The doctor is able to recognize he's being stressed, and it prevents him from invoking the survival defense mechanisms of fight ('Let's do another course of chemotherapy'), flight ('There's nothing more I can do for you — I'll go get the chaplain') and freeze (the doctor goes blank and does nothing)." Such reactions can be highly distressing to a dying patient.
When a patient asks for the impossible, like "Promise me I'm not going to die," the mindful doctor is more likely to step back and say, "I can promise you I'll do everything I can to help you. I'm going to continue to care for you and support you as best as I can. I'll be back to see you later today and again tomorrow," Dr. Kearney said.
Although Dr. Kearney does mindfulness meditation for 30 minutes every morning, he said as little as 8 to 10 minutes a day has been shown helpful to practicing physicians.
In addition, doctors can factor moments of meditation into the course of the workday — say, while washing their hands, having a snack or coffee or pausing before entering the next patient room to focus on breathing.
To deal with the emotional flood that can come after a traumatic event, he suggested taking a brief timeout or calling on a friend or colleague to go for a walk.
This is the second of two columns about communication and cancer. Read the first: "When Treating Cancer Is Not an Option"