I’m reaching the end of my hour-long initial consultation with Princess’ owners and for the most part, I feel as though everything is going well. I’ve discussed her diagnosis of lymphoma, went through the recommended staging tests, and outlined multiple treatment options for her disease. Her owners seem engaged, and asked insightful questions along the way. They didn’t flinch when I discussed the option of chemotherapy and even worked out a system where they would drop her off at our hospital before work so she could receive her treatments as planned.
When I detail the prognosis for Princess, an eerie quiet fills the exam room. Dogs with lymphoma typically survive about a year with treatment. A fair subset can live two years, but for most pets, especially those of middle age such as Princess, the expectation of living a “normal” lifespan is unrealistic. As is the case for many veterinary cancers, we are able to prolong a good quality of life for a long time, but our cure rates are low.
It’s at that precise moment, Princess’ male owner says to me, “So what you’re telling me is, the best case scenario is she will live a year?”
It’s easy to see how the emotional barometer has plummeted. Both of her owners begin tearing up and I’m losing eye contact. They are spending more time focusing on her rather than my words. Though I’ve been in this position hundreds of times, I still feel the heat rise to my face and my heart rate increase. Princess’ owners are creating anxiety for me. I don’t want them to focus on the terminal nature of her condition. I want them to continue to focus on how treatable her disease is.
“I’ve seen dogs with lymphoma live years after a diagnosis!”, I exclaim with probably more enthusiasm than the situation calls for. Instead of being the practical and sensible doctor, I find myself grasping at the outliers – searching for the random cases where I can offer hope for a “better than average” scenario.
Anticipatory grief describes the grief reaction occurring prior to an expected loss. It’s easy to understand how cancer patients or their loved ones would feel emotions associated with mourning future loss. It’s easy to understand how this would translate to veterinary medicine. Pet owners can experience sadness when thinking about loss of their companions.
What may be less easy to understand is how anticipatory grief factors in to the healthcare provider.
According to The National Cancer Institute, the following aspects of anticipatory grief have been identified amongst survivors:
- Heightened concern for the dying person
- Rehearsal of the death
- Attempts to adjust to the consequences of the death
As doctors, we experience each of these same emotions when working with terminal patients.
Advanced treatment options allow us to manage many cancers in pets as chronic diseases. In some cases, this can mean 2 or more years of treatments, with multiple examinations, lab tests, and ups and downs.
During this time, I not only become “attached” to the pets, but also to their families. We travel calendar years encompassing holidays, life cycle events, and the ups and downs inherent to life in general. It’s easy to push aside the terminal nature of the cancer, and experience the pure joy of emotion associated with helping pets live longer and happier lives with their families.
Regardless of the diagnosis, pets will not live forever. Even if they are able to outlive their cancers, there are other disease processes that will eventually reduce their quality of life. This could result from the failure of another vital organ or severe orthopedic or neurologic disease, or even the development of a second (or even third) more aggressive form of cancer.
When we know pets will die from disease, we are obligated to provide owners with realistic expectations of their outcome. My mentor during my residency would often say “We do it for the five percent.” At the time, as a fledgling oncologist, I don’t think I truly understood the magnitude of his lesson.
Now, with a few years of experience under my lab coat, I see one interpretation of his wisdom would be we keep ourselves in this crazy profession for a small proportion of our patients and their families that we will truly feel connected to.
This does not translate to mean we don’t care about 95% of our patients. It means we are able to truly connect and maintain the connection with such a small proportion.