Hope for the Best, and Prepare for the Worst

Mr. J., a 40-year-old father of two young children, has metastatic non–small-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 prospect—that 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 patient–physician 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 death need not be mutually exclusive. Both patients and physicians want to hope for the best. At the same time, some patients also want to discuss their concerns about dying, and others probably should prepare because they are likely to die sooner rather than later. Although it may seem contradictory, …