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Time is what you need it for

Interview with Annette Strömgren


 

Annette Strömgren is a Danish oncologist who since 2016 works as a consultant at the Department of Palliative Medicine, Bispebjerg Hospital, Copenhagen, Capital Region of Denmark.



Marianne Kastrup: As a doctor working in palliative medicine are you frequently met with the question: How long time do I have doctor?


Annette Strömgren: Yes, that is a frequent question, but I never answer by giving an exact time frame. I think we must be careful when answering questions where patients are looking for certainty. I prefer to answer by saying it may be weeks to months or it may be months to years. I recall a case where a patient suffering from a low malignant tumor called me in tears that she had read that you could survive no more than 5 to 10 years with her disorder and being young she was devastated by that prognosis. Nine months later she passed away. To me it has no meaning to present patients with median survival rates, as we do not know where the individual patient is located on the continuum.


So how do you deal with the wish patients have for certainty?


I take a discussion with the patient asking, “What do you hope that you may still manage to experience or accomplish?” It is never too early to start fulfilling such wishes and prioritize what matters most. When asked this question, the patient typically becomes silent and is having an inner dialogue contemplating the consequences.


In some cases, the patient may be able to fulfill this wish and subsequently even set another goal to reach. So, my advice to junior colleagues is not to be certain when asked by patients how long time do they have left.


As an anecdote I may describe how my father (professor in psychiatry Erik Strömgren MK) reacted to the answer when he asked that question. He was 83 years old suffering from a pancreatic cancer and with jaundice. But when confronted with the fact that he might live between a few weeks and 2-3 years, he responded “If I only have a couple of years left, I have to completely change the focus of my research”. He passed away few days later.


Annette Strömgren: "In some cases, the patient may be able to fulfill this wish and subsequently even set another goal to reach. So, my advice to junior colleagues is not to be certain when asked by patients how long time do they have left." Image by Unsplash.
Annette Strömgren: "In some cases, the patient may be able to fulfill this wish and subsequently even set another goal to reach. So, my advice to junior colleagues is not to be certain when asked by patients how long time do they have left." Image by Unsplash.

I frequently ask patients questions like, “What does your body tell you?” Patients have in many cases a feeling that they do not have long time left and may request whether they still may have another Christmas to celebrate. We talk about a late palliative phase and here we discuss whether there are positive aspects of life still to be expected.


I find that dignity is essential when discussing the last phase of life. In such cases I meet the patient informing that I do not come as a doctor of palliative medicine because you are going to die, but because you are still alive.


But how to help patients in the terminal phase when there is a certainty that time is short?


In a conversation with a patient in terminal phase we talk about the temporal progression of the condition, that over time the patient has experienced several episodes with an aggravation of the disease but with subsequent improvement, but that time has come now where further aggravation may not result in subsequent improvement but in a deterioration. It is instead essential to talk about how to let dignity determine the terminal phase.


"I find that dignity is essential when discussing the last phase of life."

It is important to emphasize that you as a patient may choose not to accept any intervention that may prolong the terminal phase, e.g. by accepting being nourished via a tube or receiving antibiotics.


Finally, as doctors of palliative medicine we must be aware of cultural differences and that different cultural and ethnic groups may have divergent approaches when it comes to accepting terminal care or leaving their destiny to a divine power. We as doctors can never be certain when time has come. □



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