What counts as a transition?

When prolonging life together with an acceptable quality of life no longer seems achievable, we are prompted to change the goals of care. Discussing such a change begins a process of transition that, however necessary, is also very scary. The paradigm for transition conversations is drawn from cancer medicine, when patients have no further anticancer options and stop receiving anticancer therapy. For other serious illnesses, the transitions may be more subtle. For a patient with HIV, the transition might be when antiretroviral meds no longer seem worthwhile. For a patient with heart failure, the transition might be when the patient is bouncing between pulmonary edema and renal insufficiency. In any case, talking about transitions is an uncomfortable moment for patients and clinicians alike. For many patients, making a conscious, explicit decision to stop disease-modifying therapy requires giving up hopes for living longer. For physicians, recommending the discontinuation of disease-modifying therapy often feels like failure.

Any failure is usually the result of overwhelming pathology, but physicians can't help but feel that they have been personal failures. This makes talking about disease progression difficult. As one of our Oncotalk fellows put it, “I just don't think I'm good at this. I think it's probably my own personal anxiety.”