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elderly couple on cruise
‘I confess what still trips me up at times is when a question about going on a cruise is a proxy for something more serious.’ Photograph: Alamy
‘I confess what still trips me up at times is when a question about going on a cruise is a proxy for something more serious.’ Photograph: Alamy

‘Can I go on a cruise, doc?’ really means ‘How long do I have to live?’

This article is more than 9 years old
Ranjana Srivastava

The closer a patient comes to death, the less they want to hear about their prognosis. Telling the truth while preserving hope is the greatest challenge of an oncologist

In the last few months, her luck has taken a downturn. There is theoretically a drug or two left to give but not without causing considerable toxicity and there is not even the safety blanket of a clinical trial to cast over her. Malignant nodules have broken through her skin. Her bones are protruding. She used to think sleep was a waste of time, now she can’t believe how much she craves it.

Taking in her dismay, I recall that I had earlier asked her surgeon if he could remove the first tiny focus of recurrence. It was visible and ugly and I wanted him to banish it. “No way,” he had said apologetically. “She is heading for disaster, no matter what we do.”

“Is there anything else we need to discuss today?” I asked at the end of her visit.

Glancing sideways, she says, “What do you think?”

“Go ahead and ask,” her sister says calmly.

“Or maybe just forget it.”

“It’s your decision but I think it’d be good for you.”

The patient looks at me with her dramatic kohl-lined eyes. If her mind were transparent, I am sure I’d see it arguing within. Under the desk I feel my body tense. In the end, the question comes out simply.

“Doc, can I go on a cruise?”

For someone who has never been on one, I have learnt a lot about cruises through being an oncologist. People love cruises; families enjoy organising them. An octogenarian patient just returned from a South Pacific cruise with her great grandchild while a man sent me a postcard from the Rhine. Both had been apprehensive, both returned bearing the infectious smile of a child. An anxious survivor observed that there was something about the endless expanse of water that allowed her to regain perspective.

A travel agent called me seeking details for a mildly disabled patient. Was her calcium level likely to rise again? Did I intend to treat her lung cancer? Did she need to worry about her recently diagnosed thyroid cancer? Could I furnish a copy of her CT report? Despite the patient’s consent, I found myself responding with scepticism.

“Why are you asking me so many questions when I told you she is okay?” I asked the agent.

“Because I know this is her final cruise and I want everything to be just right.”

It was a heart-warming insight into the kindness of strangers.

The laundry list of emergencies that are not covered by travel insurance prove a sobering deterrent to some, although many patients tackle it with good humour. “If I die, it will be with a better view than a hospital bed,” a patient quipped, instantly soothing his daughter’s concerns.

I can discuss the limited level of medical support on cruises while filling out lengthy medical clearance forms. Pleading with insurance companies to grant a refund on compassionate grounds is a given. “But only one person died, the others can still enjoy our excellent cruise,” an opaque operator suggested.

But I confess what still trips me up at times is when a question about going on a cruise is a proxy for something more serious. This is what was unfolding in our consultation. In asking “Can I go on a cruise?” what my patient was really asking is “How long do I have to live?”

I know for a fact that she is not booked on a cruise because after paying off her mortgage she spent her last bit of discretionary income by visiting her elderly parents in their native country. Moreover, she is prone to nausea and would hate to risk seasickness. She is a smart woman involved in medical decisions but she is also a mother who is yet to see her grandchildren being born and a wife trying to rehabilitate a dysfunctional marriage when cancer intruded. She knows time is short but can’t bear to ask how short.

A 2006 survey of 700 oncologists published in the Journal of Clinical Oncology found that 98% told their patients about a terminal diagnosis but 57% avoided providing a timeframe. Three-quarters of oncologists said they’d like to know their prognosis as well as an estimated life expectancy if diagnosed with a terminal illness because such information can influence healthcare preferences. Like their doctors, the majority of patients desire prognostic information but at different junctures of illness and the closer they are to death, the less they might want to hear their prognosis. Then there are the roughly 20% of cancer patients, often with aggressive disease, who do not want explicit information about prognosis and may suffer psychological harm by being drawn into this discussion by a well-intentioned oncologist. And like so many others area of medicine, there is woefully little information to help oncologists about the beliefs of patients like mine, who belong to a different religion or culture.

Telling the truth while preserving hope is the greatest challenge of being an oncologist. A 2012 study published in the New England Journal of Medicine showed that the vast majority of advanced cancer patients with a poor prognosis did not understand that their cancer was incurable. But tellingly, inaccurate understanding on the patient’s part was related to better communication scores for the oncologist, suggesting that physicians might reveal bad news at their own peril.

All these thoughts and the outcomes of past discussions, many gratifying and some disastrous, form eddies in my head. As my patient and her sister wait expectantly, I understand that today’s discussion about prognosis will occur in metaphors.

“When were you thinking about going on a cruise?”

“I don’t know. What do you say?”

“It depends on when you want to go and how you might feel closer to the time.”

“There is this huge ship that leaves at Christmas. It will be nice and warm then.”

I take a deep breath.

“Tell me about some other cruises.”

Her sister takes the hint. “There is the one that leaves soon and it has a mystery island stop off. Our neighbour is a nurse on leave and has offered to come.”

My patient isn’t so sure about the mystery island and actually, she is unsure about much more.

“What would you choose?” she asks, her gaze fixed firmly on mine.

It’s a discomposing question but an astute one. In my choice between the cruise this month and one nine months later lies the answer to her estimated life expectancy so I tread with care.

“I generally like to know where I am going, but the mystery island seems kind of intriguing. I’d do it as a one off.”

She nods and I am thankful for the reprieve. But it’s short-lived.

“And if we don’t blow all our money, we can look at the Christmas cruise.”

“Sure,” would be the easiest thing to say. Many people would justify this by saying there is nothing wrong with nourishing hope, especially when the evidence suggests that doctors are notoriously bad at predicting prognosis. But having closely followed the frightening tempo of her disease and the dignity with which she has conducted herself, I tell myself that I owe her complete honesty.

My silence is damning, the wait interminable.

Then she rises from her chair, squeezes my hand for what will be the final time, and says, “Thanks, doctor. We have a cruise to catch.”

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