Dr Ranjana Srivastava is a medical oncologist, accomplished author, wife, mother and Fulbright Scholar. She says caring for patients at all stages of their breast cancer journey is “inspiring and deeply satisfying”. “Unlike many other cancers, many women with metastatic breast cancer have had a long cancer experience,” Dr Srivastava explains. “I am constantly inspired by these women - their courage, patience and ability to handle uncertainty for prolonged periods. Patients might judge themselves harshly on these counts but as an oncologist, I see these qualities apparent in them.” Dr Srivastava has written several books about living and dying with cancer. Her first book, Tell Me the Truth: Conversations with My Patients about Life and Death, was shortlisted for the New South Wales Premier’s Literary Award. Her second book, Dying for a Chat: The Communication Breakdown between Doctors and Patients won the Human Rights Literature Prize. Her two books on navigating cancer, A Cancer Companion and After Cancer: A Guide to Living Well have been warmly reviewed and widely used.
Dr Srivastava remains a passionate advocate for early introduction to palliative care, noting that this pathway can ease symptoms and improve a patient’s quality of life. “In some instances, with better management of symptoms and emotions, and interventions for anxiety and depression, patients live longer too,” she says. “It’s important for people to understand that palliative care professionals don’t enter when oncologists give up … in the best situations, the two teams work hand in hand to deliver the best of care.”
Many patients come to mind here and their stories meld into one humbling one. I would say that as a parent, the stories that most touch me are those where mothers never stop caring for their children, no matter how old. Patients put aside their own suffering to worry about their children, whether it’s seeing to a graduation, a wedding, or the birth of a grandchild. Several people have related how they will endure anything as long as they know that their disabled child will be safe after they die. It is sad but also profound to bear witness to these intimacies and realise the bonds that tie a mother and child.
One wonderful woman springs particularly to mind. She had an adult daughter who was dependent on her mother for care. From the day she discovered her diagnosis of advanced breast cancer, my patient devoted herself to securing her daughter’s future in a supervised residential care facility. Between chemotherapy sessions, she would visit each facility to interview the staff and satisfy herself of its quality. When she finally decided on a facility, she undertook all the paperwork and did a meticulous job of tying up every loose end she could think of. I watched her perform these tasks even while she was having treatment and found it simply heartwarming. I heard later that her daughter was content in the facility and was being well looked after.
A patient coming to terms with her mortality is sad, but ultimately inspiring to see and to learn from. We all must die and patients who accept that their oncologist can help them live well but not necessarily longer provoke reflection at every encounter. Such patients give me hope that I can help other patients navigate this journey and also provide life lessons for every oncologist. It is very sad to let go of patients, and also their families, with whom we form close relationships, but it is consoling to hear when they are at peace in palliative care at home, or in hospice.
The first thing I would say is I wish things were different and I dream of a day when we can make breast cancer an indolent, chronic disease like some other illnesses. However, palliative care has the ability to ease symptoms, physical and existential, and to provide comfort and consolation at the end of life. Many patients share that they don’t fear dying as much as the discomfort and suffering they are expecting. Early introduction to palliative care services reassures patients that they are not alone and that we are fortunate to have access to high-quality medicines and professionals. Palliative care honors the choice of the patient and eases the burden on families too.
Fortunately, it’s becoming less common as awareness of palliative care grows but patients and families can have a reflexive response to the mention of palliative care which goes along the lines of ‘but people go there to die’.
There is good evidence that early introduction to palliative care eases symptoms and improves quality of life. In some instances, with better management of symptoms and emotions, and interventions for anxiety and depression, patients live longer too. It’s important for people to understand that palliative care professionals don’t enter when oncologists give up, rather, in the best situations, the two teams work hand in hand to deliver the best of care. I routinely broach the role of palliative care with my patients who are having active treatment and I advise them to not be afraid of an introduction. Awareness of palliative care services is important; however, I am comfortable allowing patients time to come to terms with things and let me know when they are ready to accept palliative care intervention. Needless to say, like other areas of doctor-patient communication, the discussion about palliative care, its intent and its value relies on establishing trust and rapport with patients.