[00:03] I. Intro and hello

[02:07] II. Guest - Farhan Shams, MD. Geriatrician & Palliative Care specialist

[02:49] III. What are Goals of Care?

[05:38] IV. What is Palliative Care?

[18:01] V. Who comprises a Palliative Care team, and what are their roles?

[31:00] Expectations, communication, and understanding where the patient is coming from.

[43:08] Change is the only constant in life

[47:04] Futility

[48:45] Closing

Key takeaways:

-- Palliative Care is a subspecialty and a team of professionals dedicated to improving the overall experience of a patient, family, and friends throughout the critically difficult moments of patient succumbing to disease.

-- Comprised of a physician, nurse practitioner, psychologist, social worker, and chaplain; all specialized and with a professional focus in the field.

-- Critical to establish "what are the goals of our treatment" and to ask "why are we doing what we are doing?"

--Understanding, communication, expectations, hope, reality, and process.

--Grief

--A Palliative Care doctor is a "Life Coach" for the end-of-life process

Hey everybody. Welcome to So it's cancer, a podcast to understand cancer, how it happens, how it's treated, how we arrive at a diagnosis and a prognosis cancers impact upon a person's quality of life and how to move forward in life after a cancer diagnosis. The show airs monthly and we welcome your engagement and feedback.

This is the first episode of season two. We had a, a little break between season one and two, like, I don't know, eight months, we all got busy, but anyway, we're back today and, uh, we're going to be taking on the subject of palliative care. And with us, we have, uh, our usual three, me, Paul Roach, a surgical oncologist and Peter Schlegel.

our medical oncologist and Michael Reardon, our graphic design artist. And we're very excited to, um, to welcome our special guest, Farhan Shams, who is a palliative care specialist. Hey everybody. How are you guys doing?

Doing well, Paul.

Very good. Thank you.

Excellent. Enjoying the holiday season.

Yeah, how was Thanksgiving, guys?

It was a holiday. It's over, it's good. All right, charging right into.

Yeah.

You can't get cancer like it can get a cold or the plague, right? Because every time I have Thanksgiving, I come away from it sick in some way. So please tell me, you cancer docs, that this is not something that I'm going to catch ever. No, I know. I'm just... But I always get something from the family when I'm over and when we all get together for Thanksgiving.

Ehh

Oh, cancer? No.

Yeah, last year we had a big party and it was a super spreader event. Um, you know, so you got to share it with everybody, right? Those who you love share your COVID. All right. So Farhan, uh, welcome very much. Would you be willing to just say hello and, and give us a little background?

Yeah, my name is Farhan Shams. I work with Paul at Hines B, serving our veterans in the capacity of Pentecostal Care Consultant, providing full spectrum from symptom management, goals of care assistance to end-of-life care.

Great. And Farhan and I work together weekly. I mean, I was just with palliative care for an hour and a half yesterday. Um, you know, we, we worked together very regularly and, uh, and we're. You know, very excited to have you on the podcast. All right, Peter, you're gonna. All right.

Hehehe

Thank you.

Yeah. As a medical oncologist, my goal is always to cure patients of their cancer. Unfortunately, this is not the reality for a lot of people. And unfortunately, despite their best efforts, the best efforts of the medical system, the cancer wins. There is a time where we have to say, hmm, let's make a reset here. Instead of fighting the cancer, we're going to have to concentrate on quality of life. We're going to have to let

nature take its course and unfortunately bad things are going to happen. But the key here is that we want to make the best of a bad situation. Certainly no one wants to be in the position of having an advanced cancer in which the oncologist doesn't want to treat anymore, yet that's the reality. We've seen thousands of patients fighting cancer and yet the inevitable is that in many cases cancer wins.

Now, first of all, it's important to identify what the goals of therapy are. If they are indeed curative, great, we'll go forward, we'll do everything we can. But in many cases, that is an impossible task, at least a statistically impossible task. And we're stuck with just taking care of people as best as we can. And part of that entails quality of life and how to ensure that despite whatever tears that cancer are causing.

In many cases, it can be physical pain from the cancer. Some cases, it can be people becoming globally weak. Other people, it can be loss of independence. And it's important that we identify all three or four of those, three of those areas in terms of providing the best care we can for our patients who are suffering. In light of that goal that we have, it's important to...

specify that we do have help that's available, that there are people in the medical system that are specifically oriented to helping people with quality of life. Not necessarily the agenda of the chemotherapy doctor, the surgeon, the radiation oncologist, or the family members, it's what the realistic goals are and how we can achieve a good end, if you will, how we can make the best of a bad situation.

So with that, I'm going to turn the mic over to Farhan to talk a little bit about how he feels about being a palliative care specialist, how he's passionate about taking care of people with cancer and what kind of success stories he has and some advice he can give to people experiencing cancer.

I'm gonna butt in just to ask what is Palliative? What does that mean? What's the root?

Thank you.

The word palliative means relief of symptoms, so to speak. Any suffering, how do you palliate that symptom? That's how it evolved. And there are different names for the subspecialties such as supportive care, a lot of...

units are established under the name of supportive care to help maximize symptom relief, that be the physical symptom, emotional or a spiritual distress. So overall full care of the patient, mind, body and the spirit, and whatever they're suffering with.

to relieve that suffering by using

Is this the same as hospice or is hospice the last step of palliative care?

It certainly is not hospice. Hospice is part of it. In hospice also, symptoms are palliated. Someone is having pain, relieving that pain is considered palliation of that particular symptom. Somebody is experiencing shortness of breath. Relieving that shortness of breath would mean palliating that particular symptom of shortness of breath. So when we talk about

palliative care and hospice care. The way we wanna look at it is, the goal with palliative care is to help understand patients' goals of care, what their understanding of the disease, of the disease trajectory, and what matters them the most, and to their loved ones. When you understand the patient, that's when you can tailor

the treatment plan in a much better way. I don't wanna say that oncology, yes, oncologists will offer chemotherapy, radiation therapy, pain management. Now, immune therapy, surgeons will offer surgical treatment. What does the patient really want? How much patient really understands? That...

And that, so that's where we come into play as Palliative Care providers to really understand the patient and the family. What do they really understand about the disease? And what is the intent of the treatment? Like Peter mentioned, most of the time cancer wins.

And is the intent of the treatment is curative versus palliative? And meaning, are we focusing more to slow the cancer progression and help manage their symptoms and quality of life versus the intent is curative?

So it's fair to say that our oncologist doctors here, they're treating the disease and you in palliative care, you're really treating the patient or tending to the more humanistic aspects of their patient needs.

Yeah, the whole care meaning mind body and spirit and involved psychology Support social worker support spiritual support to really address all aspects of care

I think that we could maybe just sort of make up an imaginary patient and give an example that might help sort of illustrate it. So let's say there's a patient, patient X and he's 60 years old and he's got a cancer and it's an early stage cancer and we can cure it at that point. We're not really going to. Uh,

Be focused on anything else other than curing it. Would that be a fair thing to say? Yes. And then, and then usually probably you don't get too many consults in that situation. Would you, Farhan?

So total focus on the disease.

So we do say for instance if there is a refractory pain issue. So we assist with pain management. We have a patient right now in our care that the plan is to do adjuvant chemotherapy and then possibly consult Dr. Roach for surgical intervention. This is a pancreatic cancer.

Okay.

early stage pancreatic cancer. However, he has been hospitalized three times in the past month with uncontrolled symptoms of pain. So we are assisting with symptom management in that. We are helping him and his wife go through this difficult process. I mean, he's a young Marine, 60 some year old.

Aha.

having difficult time coping. He has been up and about living his life. Now all of a sudden life has totally changed. Nausea, vomiting, pain, being in the hospital setting. He's from, he lives about three, four hours away from here. But so he's living at Fisher House, so to speak.

And life is total upside down. So we have spiritual support.

Yeah. So you need all those other elements of support that, that are not covered by the, the chemotherapies or the, the surgery or the radiation.

Exactly, exactly.

We've talked about the entire team before on some of the earlier podcasts where there's a whole team of specialists and caregivers and how important it is to know them and be sort of managing that with each group. But I don't think we've talked about a palliative care person in that team. And it sounds like, Paul, you were saying that you don't always get a palliative care person on your team.

And so it sounds like under extraordinary pain or a patient that needs like particularly help or guidance or as you were saying, like spiritual and psychological, like to help them just manage and deal with the diagnosis, you might have to bring somebody in to kind of get them on track with their, whatever the therapies that they're undergoing are. Is that?

And truth be told, this is why Peter wanted us to talk about palliative care today and why it was important to bring Farhan aboard because...

You know, like for instance, I focus mostly just on the surgical aspect and I, you know, I kind of rely on other people to bring in those, those other elements. Um, and, and Peter, uh, I'm really glad that you wanted to do this episode. And, and I'd like to hear some more of what you're thinking.

Yeah, going on the lines of this young Marine who has pancreatic cancer, but refractory symptoms with pain, I think it's really interesting to kind of go through the list of different problems he or maybe experiencing, ranging from the pain, which from one point of view is quite straightforward. The other aspects are loss of independence. A lot of people who suffer from cancer treatments.

lose their independence and where does that leave them? Who is there to help them? Say that they're single and they have a family structure that has not provided much care, they need rides to get in. Could you talk a little bit about loss of independence and how theoretically this Marine has had some difficulty getting around, having support at home, dealing with pain?

someone not to go to the drug store for him. How does the system work for someone like him who's lost his independence yet, he needs to go get his prescriptions filled, he needs to get an x-ray, he needs to go in for chemotherapy. What are some of the resources that are available for this man trying to fight his cancer?

So this particular Marine, his life has obviously drastically changed. He is now spending most of his day in bed or chair, having difficulty dealing with the symptoms and that led to three recent hospitalizations. His wife is by his side, very nice, dedicated, good.

good woman taking good care of him.

I mean, he was up and about and living his life now, emotionally dealing with that I have to be dependent on the nursing staff or our family for my daily care needs is just very stressful for him. And that's why Palliative Care, as Palliative Care Consultant, we do not go just by ourselves, we go as an interdisciplinary team.

with our psychologist, with our social worker, with spiritual support to help patients. Because it's not just one dimension that is affected. It's the whole life is upside down. And most of the time as physicians, we don't look at that. We...

I mean, our healthcare is not designed as such to provide all these multi-prong approach to someone's care who is losing autonomy and who is requiring more assistance, not just on physical, but also on a spiritual or an emotional level.

determines that? Is it you know the one of the doctors do it? Is the primary care physician? Who gets you involved? Like if you're not always on the team at what point in time does somebody say hey this requires palliative care?

So that is the decision. There are multiple approaches. One is like in this gentleman was three repeated hospitalization or two repeated hospitalization or sometimes refractory pain that oncologists feel or the primary care physician or the hospitalist feel that the pain we have done the management but it is not getting managed.

So they get palliative care on board to assist with this malignant pain management. Once we get involved, then we come as, not as a person, but as a team to address different aspects of pain, not just physical, but other pain.

What members typically are in a palliative care team?

Yeah, so physician, could be nurse practitioner, psychologist, social worker, and chaplain. These are the basic core group. And I'm lucky that I work at a veteran affair hospital, Heinz VA Hospital, at a tertiary care setting where all these supports are available.

If we go in the private community setting, I don't think all that help is readily available.

One of the things that I've noticed as a medical oncologist for people experiencing cancer is that there's definitely grieving and there's been published reports about the stages of grieving from denial to anger, bargaining, depression, acceptance and you see that pattern with most patients. Often it's not in that order but it does include all those elements.

So.

In addition to the person, the patient, experiencing the cancer, you see that in the family structure as well, in terms of the spouse, the children, and so forth. Sometimes the family's at a period of acceptance, but the patient is angry or vice versa. The dynamics can be very, very interesting. And as I've charged along in my career, I used to sense that the form of

The worst suffering would be pain. But as over time, I've noticed that it's really is loss of independence and, and being alone that they can be at a horrible, uh, detriment to, to quality of life. Um, I just, uh, you know, even for people going through a breakup, going through a divorce, going through a bankruptcy, whatever you see this pattern of, um, stages of grief going on.

And it's important to identify those to help the people progress to that hopeful acceptance as well as the family support.

Yeah, Peter, as you said, the five stages of grief, denial, anger, bargaining, depression, and acceptance, then not everybody goes through all these in order and one can go from denial to acceptance or one can go into major depression and not go to acceptance.

Yeah, it plays differently for different people. And that's why we are lucky to have our psychology support with us to help our patients cope with this, with the challenges that they're facing. And they not only work with the patient, but also with the family at large, with the spouses.

to make the best out of the situation.

So when we started this out, sorry Paul, I'm going to dominate here. We started this out, Peter you had said that the, you know, the cancer, your hope is to fight cancer in this way you're in this and yet sometimes you have to admit that the cancer will win. But it sounds now to me like this is actually for someone who's in the fight, that there's that they're under treatment and they're dealing with all of that.

You know, one thing I... Oh, go ahead, sorry.

And that was kind of why I was a little bit confused and had asked about hospice. So it sounds like hospice is the end treatment of palliative care, but you may want a palliative care team when you're in the first stages of fighting this, right? I mean, I shouldn't use stages because I know that's, it can be confusing what stage your cancer is at. I just mean, as you're beginning this journey, no matter what stage your cancer is at, you might want palliative care.

just to help you, you know, hopefully survive, but manage that whole difficult process, whether you have a strong chance or a slim chance, I would think, right?

Michael, I will say that quality of life is very important and to enjoy the journey. That people with cancer need to understand that their life may be limited and they need to do things other than just hunker down and fight the cancer as hard as they can. And when we get to a point where, hey, somebody's suffering, the medical oncologist, the radiation

symptoms adequately, then we want to involve palliative care or psychology.

Yeah, yeah, I'll answer that. Should I? Okay, so as Mike, you pointed out, palliative care can be helpful at any stage of the illness and is usually best provided soon after a person is diagnosed with a serious illness. Because...

Yes, yes please.

In addition to improving quality of life and helping with symptoms, Palliative care can help understand patient and family with their choices of medical treatment. And what is the intent? Because it is a very common theme that patients will say when we ask them.

you have a stage three cancer or a stage four cancer. Sir, do you understand what to expect from this treatment? And the answer is, I don't know.

Yeah. Along those lines, Farhan, I just like to add that as a medical oncologist, the important thing is to say, why are we doing this treatment? Why are we doing this chemotherapy? Why are we doing this hormone therapy? Why are we doing this pill? And from my point of view, there's only two reasons to do some sort of treatment. Number one is you can help the patient live longer. If it's cured, that's a big deal. Often that's not the case. But number two, can you help them live?

better. And if you cannot answer yes to either of those, then it really shouldn't be given. And people really need an open dialogue, informed decision making about any sort of treatment when they're battling cancer.

Yes.

I'd like to, to jump in right here and emphasize the importance of family meetings. Um, this is something that has gradually become more important in my own practice, which is as physicians and maybe as nurses, we assume so much and it's oftentimes wrong, like

this.

We assume that the person wants more time or we assume that they understand what we're talking about. Or we assume that we understand what the options are. And we get into the family meetings and I find out so many of the things that I was just taking for granted, you know, when they asked questions and whatnot. And this is always in conjunction with palliative care and social work. And, uh, and I discover that they were not actually on the same page. Pardon me. We're, we're not.

I wasn't where the patient or their family was at. And they're thinking that this person is either, let's say, going to get completely better and that's not realistic, or they're thinking that the person has no options and actually they do. So how would you say, Farhan, you know, with family meetings, um, like if you're talking to the patients and sort of expressing.

How do you bring them in and find out where they're at is what I'm trying to ask.

Yeah. So the first thing we start with is what is their understanding? Understanding of what's going on and the treatment options that have been presented to them. What do they really understand or and what is their expectation and what matters them the most? Is it for a stage for cancer is

to go undergo another procedure or to undergo another set of chemotherapy or immune therapy do they really understand what that means and what are they hopeful for from that particular treatment? Those extra few weeks, is that very important to them while they spend that precious time?

in the hospital setting, in a chemotherapy unit, or back and forth to the emergency room, what matters them the most? What brings meaning? What brings quality to their life? So that's...

So if I were a cancer patient and what mattered most to me, kind of what Peter's been saying is, like, I want my independence. I don't wanna be in the hospital. Is that part of your plan then where you would say, okay, you just said you wanna be at home and you need help managing that, you might need help getting here and you might need help with your prescriptions. Is that what you do? Are you gonna sort of...

work with the patient to give them, whichever direction they go, the best outcome in that direction.

That is correct. And so at the VA, I'm going to talk more about the VA setting. That's where I spend most of my life. The best part is concurrent care. VA has come up with concurrent care

disease modifying or treatment such as chemotherapy or radiation therapy, they can have hospice support at the same time, because once someone signs up for hospice care, that unlocks a set of benefits like bringing medication home, bringing 24 hour support at home, bringing 24 hour medical help available to them.

um, at their doorstep, uh, instead of them running back and forth to the emergency room or to the hospital. So if spending time at home is most important while they're still, why they still want to work with oncology to continue with their treatment, yes, they can do that. That's what we call is concurrent care.

I will add that the gap in expectations is huge. Whether it's a lack of communication, whether it's hope versus reality, that's something that's often present in these discussions. The way that I can mitigate some of this is sharing information with the family. Sometimes that includes when the veteran or patient is coming in to include their spouse or...

sibling or child in a conference call. And it doesn't take much work with modern technology to involve them in these conversations. Secondly, it's important to understand the stages of grieving that people go through stages at a different rate. So it's really important to be patient with the process and not to demand that someone accept what's going on at this point.

It's, but it's important to recognize that it is a process. And lastly, I just want to say that hope is a great thing and it helps people move along, but it is really the opposite of reality that we do have hope that we're going to cure, we're going to have a cure, and this is not going to be a long-term problem. But we also have to be realistic that, you know, things don't go as planned. No one wants to have cancer. No one wants to have an incurable.

disease. No one wants to have cancer associated pain, but that's the reality for some people and how to best face that, how best to deal with that. That's really the importance of palliative medicine and really making the best of a bad situation.

So along those lines Farhan, what options besides, okay I wanna work at home, like you were saying, we wanna talk to the patient and find out what they want, what's most important to them, what do they value? What are some of those things? You've been doing this for a while. If I'm a cancer patient, like right now I wouldn't know. I might say, could I talk to a psychologist? But that might be about all I would know to ask for. Thank you.

Yeah.

I was thinking you should do that anyway.

But Paul, dear friend, if something like this should happen to me or if one of our listeners is suddenly a cancer patient, what should I be thinking about and what are some of those plans that we might enact that I could even proactively sort of think about ahead of time as I'm going into this?

You know, first and foremost, we have to understand where a patient or family is coming from.

understanding.

the difficulty they're facing, acknowledging those emotions and addressing those emotions is more than half the battle. We, physicians tend to...

when we go into a family meeting, we, instead of asking what they understand, what patient or their family understand, what is important to them, we tend to give the diagnosis or the treatment plan without understanding what matters to the patient or the family the most.

So once we have acknowledged emotions and have delivered this serious news, getting to understand what matters them the most, that's when we can come up with a plan. Like someone may not be interested in another surgery, someone may not be interested in another set of chemotherapy. And as you said, if the goal is to be at home, to maximize

time to spend at home and to maximize quality of life and to spend those precious days or weeks or months, whatever is left in doing what matters them the most, how we as a team can make that happen. And that's what we work with the interdisciplinary team to make that happen. Like we have a patient right now.

at the hospital with pancreatic cancer. And the disease has progressed. He has ascites, he is unable to eat. Ascites means fluid in the abdomen. So, but his goal is to be at home, to go home and spend time with family and die in his own bed while still be able to eat.

How can we accomplish that? Every time he's trying to eat or swallow, he's vomiting. So we come up with a plan, okay, let's do, let's, Dr. Roach, can you do this procedure for this veteran so that we can still eat? Yes, we will suck all the food and nutrition out of his belly, but he will have the pleasure of eating.

Let's optimize his pain. Let's get hospice on board to maximize support that is needed to care for him at home. Let's bring all the medical equipments that are needed to care for him. Let's bring the hospital care to him at his home where he wants to die at and be with his family.

You know, I just had a patient this week where it was very similar situation, but he had a type of cancer. It was a lot like pancreatic cancer, but it wasn't pancreatic cancer. And so when I first met, I said, all right, let's do this operation. You know, you're a good candidate for this operation. And it's a very big operation with a lot of, uh, recovery and, and a 40% chance of some kind of problem after it, you know, small, medium or large. And, and.

And then getting to understand his situation by getting to know him better and his son better, um, and having a long family meeting, you know, and once everybody had all the information, the family decided, you know, I'm just going to have sort of a palliative, a type of smaller procedure designed just to alleviate symptoms. And, and I want to go home. That's what I really want. I don't want.

more time, I don't want to get rid of this thing. I really just want to go home. And it, I have to say it was the right decision for that family. Uh, the next person may want the operation, you know, but, uh, that's how it gets personalized and you can't personalize it until you understand who it is you're dealing with, not just the patient, but the family around them and, and what their needs are. And.

in the full context of the situation. And it just takes time and investment and it takes this palliative care specialist team that understands these things better than your surgeon or medical oncologist is likely going to.

Pete was talking about hope and about reality versus hope. So on the one hand, it sounds like the examples that we're getting, these people have a better sense of reality. So I'm kind of curious when your face would say, say that person said, okay, I'm gonna have this treatment. There's a 40% chance that it's coming back, but really I wanna cure it.

Is that where palliative care also comes in and either says, okay, I mean, we'll do everything we possibly can, or do you come in and say, we need you to step back and look at the reality, or both. Like, do you try to temper both sides of that saying, we'll treat aggressively, but we also want you to understand better what's happening so we're gonna have you speak with social workers or psychologists or.

Yeah, so honest, clear communication is very important in simple layman terms. And if

that has been communicated in the most compassionate manner possible. However, the reality is still not acceptable to that patient or family. I think early involvement of psychologist to help deliver the message in a better manner is important. And some people want to remain positive, even though they understand

that yes there is a 40% chance of cancer coming back. They wanna remain positive and that's how they function. So you have to meet them where they're at.

You know.

I think you'd need to communicate and be involved and know that it's, it's there are stages of grieving. That's how I specifically look at it. Stages of grieving, but everybody's different. The family structure is different. It is hard to look at some people that are overly optimistic. You can say, well, they're in denial. On the other hand, you have to have some hope that some of these treatments are going to work. Um, on the other hand, uh,

You know, it's just, it's a difficult balance that you don't want to say that there, probably need to cut this section. I'm sorry. I just lost my train of thought, but.

Nah.

You know, I think that what we hear commonly in this, when you're dealing with these serious illnesses, I am a fighter or my loved one, my husband, my son is always a fighter. So fight for...

Fight is a fight means different things at different stages of life. Fight for to prolong life or fight to optimize comfort. Fight to die peacefully and naturally versus fight to prolong life and be the machines for extended period of time. Fight means different for different people and it changes the goals of fight. The goal of fight changes as the disease progresses.

Well, that's interesting. Is that part of what you do is to help people sort of shift from that, no, I'm fighting for survival into a more realistic, like, you know what? I understand, I know where you're at. And I see that you're in this particular stage of grief, which is probably a little bit of denial maybe. And so you're kind of channeling them into using that energy to its best possible outcome, which it sounds like...

I'm glad you said that, yeah.

especially if you know that this is gonna be a terminal patient ultimately. And that could be weeks, months, years, but it sounds like your job is to basically give them that fighting chance for whatever is the best potential out there.

I think of the expression that change is the only constant and that is throughout our entire life, but it's most dynamic at the extreme. So with the newborn, you know, they're changing every day, every week, every month, you know, and then in the middle of our lives, we're not changing quite as dramatically all the time, but at the end, everything starts changing again, pretty dramatically. And.

Like Pete said, when you're hopeful and what like Farhan said, when you're fighting, well, when you're 30, you're hoping for this, or when you're 50, it's that, and 80, it's that. Or if you're not anywhere near your own death, you're hoping for a certain set of things. But then when it's very close, you have to change and you start fighting for and hoping for very different things. And I think...

You know, with Peter talking about the stages of grief and Farhan talking about this is it's redirecting all of this and, and saying, all right, you know, it is no longer helpful to try to concentrate on, let's say, beating this cancer disease that's, that's not helping any longer because we're not at that point any longer and, and I imagine Farhan a large part of your

Your mission is to help patients and families redirect as things are changing, as the reality on the ground is changing.

Yeah, our intent of our involvement and doing these meetings is to help clarify their understanding, elicit their goals, what are they hopeful for, and make recommendations to help meet those goals. And if there is a discrepancy,

in patients own understanding and goals, we have to rectify that by using structural structure, what we use in these vital talks, acknowledge emotions, but never talk them out of their goals.

wants to die peacefully and naturally at home, but still wants to remain full-cored and undergo resuscitation at the end of their life when they have advanced or terminal illness. We know that those things do not go together. That will mean that you will likely die in the ICU on a machine. So the choices matter. How we help

Clarify that that's a difficult thing, but you have to acknowledge emotions, address those emotions, and move conversation slowly further and further. Dr. Roach and I had a mutual patient, and that patient or their family did not want to hear anything negative. That person had multiple surgical interventions, and any...

any chance that they could take any procedure that could have been provided to prolong life.

was acceptable, and that meant that person spent last five, six months in the hospital setting undergoing multiple procedures. So we were there to support them to get through that difficult time, but not to talk them out of their goals.

Yeah, I will tell you that that's one of the toughest areas for a medical oncologist, a chemotherapy doctor, to define when a treatment becomes futile. Certainly I'd like to have a great treatment that has no side effects. And unfortunately that works for a while and then it doesn't work. And then you can pick a second treatment that probably doesn't work as well, maybe more toxicity. And eventually.

you'll get to a point where you can predict that there's gonna be a flip-flopping of toxicity greater than benefit. Yet there may be some statistical 10, 20% chances could work, and when exactly do you tell somebody, gosh, I think I'm out of options? And it is important to say what the cost of this treatment are, not only financial, but of course to your body, what is the value? And then...

What are we trying to achieve with this? Are we trying to stop the cancer from growing? Are we trying to improve the symptoms? Can we help someone live longer? That sort of thing. But moving along with cancer, it's always very important to reinforce what the goals of doing something are.

You know, from all of the discussion that we've had, it feels like, Farhan, your job is life coach for a cancer patient. And yeah, I think that's kind of a good way of thinking about it because people know in their life and a healthy life, I have goals and I want a coach to help me get to those goals. I want to become a writer. I want to lose 150 pounds, whatever it is.

You can say that.

Yeah.

So it sounds like you have a much more difficult aspect of that because those things are often like, oh great Let's go do that And it sounds like you sometimes have to bring them into a reality But I know we don't have a lot of time left, but and I think we could we could Discuss palliative care more because I think there's a lot of doors that we could open here But yeah, it's just an interesting thing I had never heard of it and I just really like the idea that if I'm in this difficult spot

that there's a coach that will help me get through it. And I'm glad I have the oncologists, those mad scientists who are just going after the disease, but I'm also glad that I have you that can help me manage and navigate and meet my goals and really help me understand my goals at the same time. So that's great, thank you.

Thank you.

Well, I think that sums things up perfectly. And Farhan, do you have any other things about palliative care that you'd like to share with the audience before we sign off or Peter?

No, I think I use sometimes best case scenario.

realistic scenario and worst-case scenario to help patient to drive the point home to help patients and the family really understand what to really expect when we are in take up the situation.

All right, all right.

So thank you very much for giving me the opportunity.

OP

No thank you, I thought it was fascinating.

Yeah. I would like to just add that along the journey of cancer, it's important to enjoy the journey.

Oh, it was great.

that no matter what you're going through, you need to have some quality of life. And even if it's hunkering down to do chemotherapy, you need to enjoy that time that you have. No matter what life throws at you, you need to be proactive and look at the positives, be grateful, use your support as much as you can, use your resources as much as you can, and enjoy the journey.

Well, all right, everybody. Thank you very much. Uh, thanks to the, to Farhan Shams. Thank you very much for coming and, uh, Peter and Michael, I really appreciate everything. And, uh, and to the audience, thank you for listening. And again, if you have a topic you would like to have us discuss or comments or feedback, please either log on to www.PaulBrianRoach.com and click on the about and contact page or send your thoughts directly to letters at

PaulBryanRoach.com that's Brian with a Y. Thank you again, everybody. And have a great night.

Good night.