Du corps-à-corps avec le cancer et ses traitements : vécu des modifications corporelles dans les hémopathies malignes

Patients’ bodies are altered by the disease and the treatments. These images come to saturate the psychic space of the subject. In the hand-to-hand relationship of the subject with the medical team, we question the effects of health care workers’ look on the patients’ perceptions of their bodies. The care would ask for a look “in hollow”, a “watchful eye”, susceptibility to welcome the subject and to open up him/her to his/her words.     

Sibling stem cell donor experiences at a single institution

Allogeneic bone marrow (BM) and cytokine mobilized peripheral blood stem cell (PBSC) transplantation can be curative for patients with malignant and nonmalignant hematologic diseases. Siblings are most often selected as a donor match; however, research on sibling donors is limited and has focused primarily on conventional BM donors. This exploratory study describes the experiences of PBSC sibling donors at a single institution. Through retrospective interviews, 14 sibling donors shared their perceived needs and concerns before and after their stem cell collection. Donors identified fears about the donation procedure, and expressed the need for more information about transplant outcome and complications. The inclusion of the sibling donors themselves, rather than the report of their parents or health-care providers and the qualitative nature of the structured design allowed sibling donors to describe their concerns and thoughts without being restrained by the beliefs of the participant's parents, researcher or sibling's medical team. Suggestions for visual educational tools, psychosocial interventions and future research are provided.     

Physician-patient relations and decision in oncology

The doctor-patient relationship has evolved during the past decades. This is particularly prominent when the patient's participation to the medical decision is analysed. The interest of the patient includes his (her) autonomy for which it is necessary to inform about different possibilities of treatment before informed consent. However each patient has his (her) personal characteristics and thus different wishes to be informed and to participate to medical decision. Moreover, this wish may change along the evolution of the disease. Thus, patients must be asked about the kind of relationship they prefer with the physicians. In all cases even if this relation is good, two kinds of barriers remain which are technical and emotional. Except in rare cases, patient cannot understand all the numerous medical data which are taken into account for the decision. Furthermore, since he (she) is personally concerned, it is difficult for him (her) to judge objectively and to think about a future which is hopefully positive after immediate reactions or hazards due to treatment. But his (her) advice must be asked and taken into account by the physician along with other parameters to choose the best option for the interest of the patient.     

Toward Eubiosia: Bridging Oncology and Palliative Care

How can oncologists approach patients with advanced and progressive cancer and yet not rob them of hope? In this edition of The Oncologist, four articles lend context to the issues regarding the bridge between palliative care and oncology.Open in a separate windowDon S. DizonShe wasn’t my patient, but she was my friend. When she was diagnosed with breast cancer, I had to put aside the fact that I was an oncologist so I could support her. We talked about meetings with her doctors and what they said. She was very comfortable with her team, and the treatment plan laid out for her made sense to us both.Over the next few months she underwent neoadjuvant chemotherapy, bilateral mastectomies, postmastectomy radiation therapy. Then she was deemed to be in remission. Unfortunately, within 18 months, she had developed metastatic disease. Again, acting as friend and not as doctor, I quietly listened as she spoke of trying to remain hopeful but of fearing the future—what would become of her boys, her mother, her husband. She wanted to live, but she also knew the odds of her living more than a few years were not good.As months passed, treatment took its toll on her, and I wondered if her team talked with her about palliative care. She would tell me only of the next treatment planned and what the latest computed tomography scan showed. The conversations she had had with her doctors, as she related them to me, never seemed to touch on the elephant that was very clearly in that room.This situation illustrates a dilemma for many oncologists. How do we approach patients with advanced and progressive cancer and yet not rob them of hope? In addition, although there is widespread agreement that early integration of palliative care is important, the barriers that exist for oncology clinicians and their patients are ever present.In this edition of The Oncologist, four articles lend context to the issues regarding the bridge between palliative care and oncology. Hui et al. present a systematic review showing the lack of a universal definition of what, exactly, integration between these specialties entails. Furthermore, they identify a potential factor to explain why clinicians do not engage with patients early on. Our literature does not guide us clearly on what it means to do just that: although 65% of articles reported on early integration, only 20% actually provided specific timing that defined this concept.Beyond the procedural and institutional barriers, Winkler et al. report the findings of a qualitative study that involved 18 clinicians (12 oncologists, 6 nurses) and investigated how one group communicated with patients about the end of life. They describe two approaches: proactive facilitation (i.e., clinician-initiated discussion) and a more passive stance (i.e., wait until the patient brings it up). Each reflects a delicate balance of the objective data in oncology (the evidence basis of our recommendations) and the emotional stances that both clinician and patient bring to each visit. Some are willing to approach the elephant in the room head on, whereas others are more comfortable keeping it in the proverbial background, waiting to take the patient’s lead.Regardless of what one thinks “early integration” means, and regardless of how one approaches such difficult conversations, the importance of that information, that conversation, and that knowledge cannot be emphasized enough. Patients look to us as oncology professionals for guidance and truth—truth so they can make informed decisions about treatment for cancer and about their lives, because of cancer and despite it. Part of that truth is to help point out changes in prognosis: when the cancer is no longer curable; when treatment is no longer a good idea; when they have reached a terminal phase of their cancer; and, yes, when they are nearing death. The significance of these moments, for both our patients and ourselves, is illustrated in the two narratives published in this issue.Dr. Tanneberger reflects on his long experience in oncology, charting a career that has spanned four decades, and introduces us to the term eubiosia, which means dignity in life “until the last moment.” He shares his own experiences with two patients from very different parts of the world. In one experience, a woman with metastatic breast cancer shows us that one can live alone and not be lonely. She finds companionship with a bird that she had saved from death. It is pet therapy as eubiosia. The other is the experience of a man living in India who finds happiness and peace in the midst of family, despite the fact that he lies on a bed in the street. These anecdotes emphasize that, often, it is not technology and medicine that lead to good quality of life but rather the simple things—companionship, friendship, family.These themes are brought home by Dr. Ben-Arye, who writes of an experience caring for Vasily, a 51-year-old man with metastatic prostate cancer. Caring for him alongside his nurse, Bella, they share a memory of their ancestors from World War II. Intertwining stories are revealed, of Vasily’s grandfather as a German Gestapo agent, of Bella’s grandfather as a Soviet soldier, and of the author’s grandfather as a Jew in the British Army. That they would recount these memories together during the last moments of Vasily’s life seems shocking. However, the memories of the past had been replaced with safety for Vasily and enhanced care and compassion for his providers.Although different in their scope and objectives, these four papers provide a view into the complexity and importance of communication among oncologists and our patients, of palliative care, and of acknowledging the end of life. They illustrate the work that has been done toward earlier and wider access to integrated palliative and oncology care. In addition, they point a way forward for us by standardizing integration and concepts of early referral and valuing quality of life as much as any tumor response measurement.Within the narratives, the science finds a new voice; hopefully, it is one to which we all will listen. Ultimately, they remind us that our goals must be to help our patients achieve peace and joy, even at the end of life. The goal of eubiosia is what I wished for my friend and what I strive to achieve for each of my patients.     

Guiding patients facing decisions about "futile" chemotherapy

Ms. G is a 71-year-old woman with metastatic gastric adenocarcinoma recently diagnosed after an extensive surgical resection for a small bowel obstruction (SBO). She was admitted from the surgery clinic with intractable nausea and vomiting. An abdominal computerized tomographic (CT) scan revealed a partial SBO and peritoneal carcinomatosis. Given her recent surgery, the extent of her disease, and high likelihood of recurrent SBO, the surgical team decided that Ms. G was no longer a surgical candidate. When her symptoms did not improve with conservative measures, both oncology and palliative medicine were consulted to assist with symptom management and goals of care. The oncology team stated that Ms. G was still a chemotherapy candidate and suggested that she attend her new patient evaluation in oncology clinic the following week. The palliative medicine team then met with the patient to discuss management options and her preferences for care. The palliative care team explained ways to control her nausea and vomiting without using a nasogastric tube, and the patient agreed to transfer to their service for symptom management. The palliative team explained that her cancer was incurable but that chemotherapy options existed to help control her disease and possibly prolong her life. They also explained that the chemotherapy has side effects and that the patient would need to decide if she wanted to undergo treatment and accept potential side effects for the possibility of prolonging her life by weeks to months and improving her symptoms. As an alternative, she was told that she could focus solely on symptom control with medications and allow her disease to take its natural course. Ms. G was asked to think about how she wanted to spend the time she had left. Prior to discharge, as her symptoms improved, Ms. G was evaluated by another oncologist, who, after consulting the expert gastrointestinal cancer team, explained to her that the current chemotherapy options available for metastatic gastric cancer were rarely, if ever, successful at reversing malignant obstruction. With this information, the patient decided to be discharged home with hospice and spend time with her family. She died peacefully at her home approximately two weeks later.     

Adolescent confronting cancer and its place in the family

Adolescent medicine is expanding in Europe with particular attention being given to cancer of adolescents and its treatment. At a time where specialised units for adolescents are being born, it is essential to collect the current knowledge on the pathological impact of the illness in this age period whose limits themselves are often blurred (13-21 years or 15-25 years). Adolescence is a transition between childhood and adulthood, during which one seeks psychological and emotional development. Cancer, by its direct repercussion on the adolescent and also by the disorganisation of the family, can involve risks impending the process of maturation and can also be a purveyor of psychological after-affects. The occurrence of the illness can isolate the adolescent and leak to a restriction of the psychological investment. The reality of possible death can hinder the ill adolescent from developing his natural opposition to the adults who represent authority such as parents or nurses, thereby hindering access to autonomy, independence and identity construction. One can find oneself locked in a state of trouble, confusion, becoming a stranger to oneself, with an impression of distance waxing between the young patient and others. The parents find themselves weakening and must make calls on their supporters. The siblings see their daily life becoming more unsettled and find themselves confronted by parents less available and reassuring. The impact on the brothers and sisters vary depending on their age and the capacity of the parent's adaptation. From the onset, adolescents struck by cancer necessitate an adaptation of the medical staff. The medical information, the treatment and the aid-care contracts must be approved by the adolescent himself but the parent's involvement remains essential. It is necessary to create an alliance of three. Conflicts and rivalry occur frequently between parents and the medical staff. One must study the possibility of creating a place adapted to care, with flexible surrounding, respecting the identity of the adolescent while supporting his educational or professional investments and his personal interests revolving around the exterior world. The psychological and social care must be accessible to all the family members. The terms and conditions of this psychological and material support are itemised.     

Palliative home care of a breast cancer patient with esophageal metastasis after the operation of gastric fistula and tracheotomy--a case study

A 66-year-old woman felt dysphagia gradually seven years after an operation of breast cancer. We diagnosed her with esophageal metastasis of the breast cancer, and carried out irradiation and outpatient chemotherapy. Because her general condition became worse after the treatment for about four years, we performed an operation of gastric fistula and tracheotomy to manage her nutrition and of an accidental swallowing. Although the patient and her family resisted a discharge from hospital due to the progressive nature of her illness and change in physical surroundings, she was eventually switched to take a homecare medical treatment with the support of a team care approach. The main purposes of the homecare treatment were to manage gastric fistula including the administration of anti-cancer drugs, cervicobrachial pain control and tracheal cannula exchange. Though she was mentally stable and got along well with the family during the home stay, she was hospitalized again two months after the homecare treatment because of aggravated symptoms and the family's fatigue. We respected the value of her quality of life and gave careful considerations to support her during the entire period of re-hospitalization. She gently died two months after re-hospitalization. We considered that this palliative home care could be realized with the palliative team care, nursing intervention visit and family support.     

Historical Threads in the Development of Oncology Social Work

As the Association of Oncology Social Work celebrates its 25th year, we pause to reflect on the many historical threads that contributed to its development and hear from each of the presidents who helped create the organization, as we know it today. Set within hospitals, medical social work was born in the early 20th century. In the 1940s medical social work became necessary for hospital accreditation. Two additional historical shifts, one in medical improvements in treating cancer, the other a shift to a consumer-oriented American Cancer Society, contributed to the push for a greater role for the federal government in funding cancer research. Oncology social work came to full blossom in the 1970s, a result of the physicians’ need for a member of the health care team who understood cancer, its treatment, and the patient's need to address his or her psychosocial needs resulting from cancer. Today, oncology social work is a fully developed profession with a national organization providing education and support to oncology social workers’ in their use of psychosocial interventions and research in behalf of cancer patients and their families.     

L’enjeu psychique de la restitution aux équipes

In a hospital environment, the usual remarks from a team at the end of psychologist interviews with patients are a request for “restoration of teams”. This exchange, be it formal or informal, cannot aspire to the intimacy of patients without damaging their integrity. But what is the reason for this request? Serious disease confronted with the fantasy and reality of death and the psychic defences it generates colour the patient-professional relationship. This deadly impregnation clouds the relationship in confusion, which distorts the understanding of the psychic process within patients but also within professionals themselves. The author thinks that the psychic issues in the restoration of teams targets this readjustment which is essential to a treatment regime and to which the psychologist can contribute. This process requires listening to the psychic functioning of teams who are responsible for accepting questioning of their own intimacy and for being involved in this link with psychologists. For the psychologist, this delicate work calls on his/her inner position; torn between two intimacies, that of his/her relationship with the patient and that of the team, he/she needs to have a division so that he/she can partly suppress his listening of one in order to better hear the other.     

Refusing treatment: patient responsibility and autonomy. About a French National Consultative Ethics Committee statement(no 87, April 2005)

A recent French National Consultative Ethics Committee statement confirms that medical doctors are required by law to accept a patient's refusal of treatment, even if the consequence is the loss of chances of being cured. This refusal raises difficult clinical and ethical issues. Respecting a patient's decision is only valid when he/she is fully responsible, able to understand the proposed treatments and the consequences of his/her refusal, uninfluenced by friends and relatives, ignorance, disarray, an excessively pessimistic appraisal of the situation, a conflict with the doctors or with medicine. Doctors must avoid passively accepting a refusal without discussion but must also avoid paternalism or moral pressure. Adequate mutual knowledge of the way they think, their values and their objectives helps to maintain mutual respect and confidence in the patient-doctor relationship: the doctor is not a "supertechnician" nor is the patient a treatment consumer. Information, knowledge of the possibilities and limits of current medicine and of patients'complex, conscious and unconscious motives (which justifies the psycho-oncologist's role), recommendations of medical societies, experience of difficult ethical issues help to avoid unauthentic refusals, conflicts and staff burnout.     

Représentations du cancer en fin de vie: temps, espace et regard de l’autre

This study aims to understand, qualitatively, the life experience of cancer patients hospitalised in a palliative care unit. Analysis of interviews with six patients reveals four essential dimensions of life experience bond to others, acting into space and on space, the experienced time, sense of the disease and of life. Going beyond these invariables, we highlight in each patient’s discourse his or her particular relationship with others, with time and space and with his or her body. This special relationship underpins representations which enable patients to think about their experience of incurable cancer and palliative care.     

Familial cancer diagnosis

Familial clustering of cancer is well known from epidemiologic studies. This can be due to chance, shared environmental influences, shared genes and chance-environmental-genetic interactions. Family studies are a key to the understanding of the environmental and genetic etiology of chronic disease. Cancer families are human models of susceptibility to neoplasia. More and more people are aware of, and anxious about, their cancer risk. High-risk individuals can benefit from prevention and early detection programs. In medical practice the patient workup should include a carefully obtained family history. This low technology method has the potential for reduction of cancer morbidity and mortality. Every person should create his/her own family tree and discuss it with his/her doctor. This is a step each individual can take for his/her health.     

A child and parent illustrating non-compliance with treatment: understanding non-compliance with treatment

BACKGROUND: In children and adolescents non-compliance with treatment is a major concern. To shed light on its mechanisms, we present a family demonstrating non-compliance. PROCEDURE: B, a 10 year-old boy, treated for medulloblastoma, refused high-dose chemotherapy and Autologous Bone Marrow Transplantation. Six psychotherapeutic interviews with B, his parents and staff resolved the causative issues. RESULTS: B's behavior expressed his parents' ambivalence, despite their informed consent. Their reasons were conscious and unconscious, rational and irrational, linked to both the past and present experiences. The mother was convinced that he would die. The discussions helped both parents to assume their parental role, B perceived their ability to truly accept the treatment and support him. CONCLUSIONS: Non-compliance should not be viewed as a child's or parents' intrapsychic problem, but as the result of multi-determined interaction between the child, the parents, the staff interacting with present and past events. When the child's death is a possibility, the parents' ambivalence confuses their understanding and acception of the therapy. The development of confidence between the staff, the child and parents and clear agreement about the goals of therapy is necessary to avoid the occurrence of and escalation of non-compliance, which raises difficult clinical, legal and ethical questions.     

Survivors of childhood sexual abuse diagnosed with cancer: managing the impact of early trauma on cancer treatment

The incidence of survivors of childhood sexual abuse (CSA) diagnosed with cancer is unknown. It is estimated that one in three women and one in six men in the United States are survivors of CSA. Survivors of CSA diagnosed with cancer are presented with multiple and potentially accumulating traumas. The re-traumatizing nature of a cancer diagnosis and treatment affects all elements of the CSA survivor's care and may impede her/his treatment. To date, the impact of CSA on the medical treatment of people with cancer has been unexplored with the existing studies on female survivors of CSA with cancer focusing on the post-treatment experience and their higher incidence of sexual dysfunction. This article describes the impact of CSA on the cancer treatment of 18 survivors of CSA and the clinical interventions used to address the unique psychosocial needs of this population. Anecdotal information suggests that the survivors of CSA may find aspects of the cancer experience reminiscent of their history of abuse. All 18 survivors of CSA experienced distressing memories of their abuse during their cancer treatment. Fifteen CSA survivors presented traumatic memories that were inaccessible to conscious thought processes prior to their cancer diagnosis. Psychodynamic interventions address issues of disruption in the cancer treatment, non-adherence, and difficulties in relationships with the health care team. Containment of intense affect and distressing thoughts rather than exploration improved CSA survivors' adherence with cancer treatments. The acquisition of self-comforting skills helped CSA survivors feel less re-victimized by their cancer experience. The establishment of an environment of internal and external safety improved communication with the health care team. Health care/psychosocial clinicians' awareness and use of appropriate interventions can minimize the affects of re-traumatization and enhance the CSA survivor's treatment experience.     

Caring for colleagues

Shortly before his death in 1995, Kenneth B. Schwartz, a cancer patient at Massachusetts General Hospital (MGH), founded the Kenneth B. Schwartz Center. The Schwartz Center is a non-profit organization dedicated to supporting and advancing compassionate health care delivery, which provides hope to the patient, support to caregivers, and sustenance to the healing process. The center sponsors the Schwartz Center Rounds, a monthly multidisciplinary forum where caregivers reflect on important psychosocial issues faced by patients, their families, and their caregivers, and gain insight and support from fellow staff members. Caring for colleagues who develop cancer is a privilege woven with an extra dimension-caregiver-patient issues. As well as stretching the usual need for a supportive relationship, when one of the health care team develops cancer it particularly provokes concerns about our own mortality. The case is presented of a well-known physician who developed a second cancer and has been cared for at the MGH Cancer Center Staff discuss her care as it has been effected by her status as a colleague. They perceived unique barriers to optimal care such as assumptions about the patient's level of medical knowledge, and technical, informational, emotional, and hierarchical issues that may obstruct the development of a trusting relationship between caregivers and the physician/patient. Emotional stress may prevent the sharing of an accurate prognosis. In the case under consideration, the patient had a frank and open attitude to her cancer yet her caregivers were concerned about continual breeches of patient confidentiality. Despite the many potential problems inherent when the caregiver becomes the patient, this case discussion was a poignant reminder of the unique challenges of every experience with cancer and the weighty privilege of being involved with patient care.     

An Exploratory Study of Communication,Gender-Role Conflict,and Social Support of Parents of Children Treated at Children's Hospital

This article explores the relationships between communication and social support of parents of children with cancer (N = 44), and the importance of gender-role conflict in fathers. Structural equation modeling and the Actor-Partner Interdependence Model were used to test the expected relationships between communication, social support, gender-role conflict, and anxiety, and to control for sample nonindependence. Results suggest communication increases perceived emotional and instrumental social support between parents, and instrumental support from fathers results in less anxiety for mothers. When fathers experienced more conflict about their role as financial supporter for the family (i.e., career achievement gender-role conflict), fathers perceived less instrumental and emotional support from their wives. However, fathers who experienced more conflict about career achievement were also less anxious. A second measure of fathers’ gender-role conflict (i.e., emotional expression) was unrelated to either mothers’ or fathers’ outcomes. The role of gender, communication, and social support in the context of pediatric oncology is discussed.     

Survivors of Childhood Sexual Abuse Diagnosed with Cancer

Abstract

The incidence of survivors of childhood sexual abuse (CSA) diagnosed with cancer is unknown. It is estimated that one in three women and one in six men in the United States are survivors of CSA. Survivors of CSA diagnosed with cancer are presented with multiple and potentially accumulating traumas. The re-traumatizing nature of a cancer diagnosis and treatment affects all elements of the CSA survivor's care and may impede her/his treatment. To date, the impact of CSA on the medical treatment of people with cancer has been unexplored with the existing studies on female survivors of CSA with cancer focusing on the post-treatment experience and their higher incidence of sexual dysfunction. This article describes the impact of CSA on the cancer treatment of 18 survivors of CSA and the clinical interventions used to address the unique psychosocial needs of this population. Anecdotal information suggests that the survivors of CSA may find aspects of the cancer experience reminiscent of their history of abuse. All 18 survivors of CSA experienced distressing memories of their abuse during their cancer treatment. Fifteen CSA survivors presented traumatic memories that were inaccessible to conscious thought processes prior to their cancer diagnosis. Psychodynamic interventions address issues of disruption in the cancer treatment, non-adherence, and difficulties in relationships with the health care team. Containment of intense affect and distressing thoughts rather than exploration improved CSA survivors' adherence with cancer treatments. The acquisition of self-comforting skills helped CSA survivors feel less re-victimized by their cancer experience. The establishment of an environment of internal and external safety improved communication with the health care team. Health care/psycho-social clinicians' awareness and use of appropriate interventions can minimize the affects of re-traumatization and enhance the CSA survivor's treatment experience.     

Integrative Palliative Care: Between Antipathy and Grace

The author reflects on the therapeutic journey of developing a patient-centered care program aimed at relieving the patient’s concerns and improving his quality of life and well-being.As a family physician responsible for managing an integrative oncology clinic in the northern Israeli city of Haifa, I have encountered many challenges in how I communicate with my patients. Patients referred to the integrative oncology service, operating within a conventional oncology service, come from a wide variety of cultural backgrounds and health beliefs. For the past 6 years I have worked in a full-time capacity as an integrative physician, following extensive training in supportive care and a number of complementary and integrative medicine (CIM) modalities. Our integrative oncology team includes 15 trained integrative oncology practitioners, including two registered nurses whose mission is to improve patients’ well-being during the difficult process of anticancer treatment.Patients are referred by their oncologist, nurse oncologist, or psycho-oncologist to an hour-long consultation with the integrative physician who explores the patient’s narratives, expectations, and needs and tailors a patient-centered therapeutic program. The initial patient assessment and ensuing weekly CIM treatment sessions may include acupuncture, guided imagery, touch therapy, or guidance regarding nutrition and dietary supplements. The integrative therapeutic process also entails a sense of being, of contemplation—of providing an open space that allows me to meet the other.For the past 2 years I have worked every Sunday with Bella, an oncology nurse with training in manual Chinese medicine treatments. Bella joined our integrative team with a passion for touch therapy. The weekly CIM encounter with patients exposes us to their suffering but also to their joy when attaining a good result from our treatments. During these interactions we often find ourselves meeting not just the other (i.e., patients and caregivers) but also ourselves. This delicate moment introduces us to our own narratives, as can be seen in the case of Vasily.Vasily, a 51-year-old married man living in a small town in northern Israel, was admitted to the oncology service with a diagnosis of metastatic prostate cancer. He began anticancer treatment with bicalutamide (Casodex; AstraZeneca, Wilmington, DE, http://www.astrazeneca-us.com), goserelin acetate (Zoladex; AstraZeneca), and zoledronate (Zomera; Novartis, Basel, Switzerland, http://www.novartis.com) and was referred by his oncologist to the integrative oncology center for consultation. The stated reason for the referral was Vasily’s intention to take a dietary supplement, which his oncologist asked me to check for safety and efficacy. At our first encounter, I was impressed by the patient''s kind facial expression. Vasily had only a basic level of Hebrew, despite living 15 years in the country after emigrating from the Republic of Belarus. Despite the advanced stage of his disease, Vasily continued his daily work at a family-run grocery shop, where he worked with his wife and two children.I began the consultation by asking Vasily about his expectations regarding the integrative medicine consultation. Vasily was direct and clear: he expected me to advise him on the value of the homeopathic remedy Conium maculatum for treatment of his prostate cancer. The herb in question, popularly known as hemlock, is extremely poisonous, although the homeopathic form has undergone numerous dilutions and contains negligible quantities of active components. Acknowledging Vasily’s expectation that I focus on the curative potential of the homeopathic remedy, I suggested that we explore additional concerns related to outcomes for quality of life (QOL). Vasily revealed that he had been suffering from fatigue and hot flashes that were significantly impairing his daily function. At the end of our first conversation, we jointly agreeing to define two integrative treatment objectives: providing a recommendation regarding the curative role of the homeopathic remedy Conium maculatum for prostate cancer and providing a CIM treatment regimen to reduce his symptoms and improve his overall QOL. A follow-up appointment was scheduled, and Vasily was referred to one of our integrative nurses for CIM treatments.After my encounter with Vasily, I searched the medical literature for any evidence of effectiveness and safety of homeopathic Conium, primarily with respect to prostate cancer. Surprisingly, a PubMed search found two in vitro studies on Conium and prostate cancer cell proliferation, although neither revealed beneficial effects [1, 2].At our next conversation, I showed him my findings, and we agreed to focus on his symptoms, which were related to the hormonal treatment. The literature contains several studies supporting the use of acupuncture [3] and sage (Salvia officinalis) [4] for reduction of hot flashes and of acupuncture and acupressure for cancer-related fatigue [5]. During the weeks that followed, Vasily attended weekly 30-minute sessions of manual therapies (tuina and acupressure) provided by Bella, our integrative nurse. Occasionally I would treat him with acupuncture. His symptoms improved significantly, as did his sense of well-being. This improvement was also evident by Measure Yourself Concerns and Wellbeing (MYCAW) [6] scores at 6 weeks compared with the initial assessment, with decreases from 4 to 1 (on a scale of 0 to 6) for hot flashes and from 4 to 2 for fatigue.At his 30th treatment follow-up visit, Vasily was reassessed by Bella, who reduced treatment frequency from weekly to biweekly. I had asked Bella to present Vasily’s case at our weekly staff meeting, and she was eager to provide an in-depth understanding of the integrative care experience. Her next discussion with Vasily was open and informal, involving no assessment questionnaires. Vasily informed Bella of his satisfaction with her devoted care, especially considering that the CIM treatments took place in the very same department where the chemotherapy was being administered. He told Bella about his emigration from Belarus to Israel, as a Christian married to a Jewish wife, and of his decision to undergo circumcision. He then told Bella of his vivid memories of his grandmother, brutally murdered by Soviet soldiers after the liberation of Belarus as an act of revenge. His grandfather had been an employee of the German Gestapo during the war. Despite the gravity of this revelation, Bella continued the interview, at the end of which she thanked him for trusting and confiding in her by sharing this secret.It took Bella and me several days to process our feelings about Vasily’s unsettling revelation, although we shared admiration for his courage in disclosing his grandfather''s story. Bella told me her own story, of her grandfather who had fought and died during World War II as a Soviet soldier fighting the Germans. And I could not avoid the memory of my own grandfather who had served in a Jewish unit of the British army and was captured by the Germans in Greece in 1941, along with hundreds of other Jewish soldiers recruited in Palestine for His Majesty''s Army. On his way from Greece to a prisoner-of-war camp in Europe, my grandfather witnessed SS Reichsführer Heinrich Himmler ordering his officers to treat Jewish prisoners in the same fashion as captured British soldiers and not as “ordinary” Jews. Crossing the Corinthian Canal, my grandfather recalled his passage 3 years earlier, from the western bank of the canal to the east on his way from Lithuania to Israel. My grandfather and his fellow Jewish British war prisoners were eventually transferred by the Nazis to a series of labor camps in Eastern Europe. From there they were forced to march, between 1944 and 1945, more than 1,000 km westward with the retreating German forces, where they were eventually liberated by the American army.Contemplating our intertwining stories—Vasily''s, Bella’s, and my own—I envisioned the unlikely event in which our three grandfathers met, just as their grandchildren were doing now: one a Gestapo agent, another a Soviet soldier, and the third a Jew in the British army corps. We were all third-generation descendants of the tragedy of World War II, each with our own historical narrative. What was it that led Vasily to reveal his secret, leading to this interaction among the three of us—a situation unimaginable to our forefathers? Could it be his encounter with a life-threatening illness or perhaps his gratitude for our treatment that encouraged him to open up? Was it a sense of coherence and containment provided by Bella, who had touched him both spiritually and physically?I began to rethink my own role as a dually trained physician, in family and integrative medicine, who at times experienced being rather than practicing doing. I closed my eyes, allowing myself to greet mindfulness. How had this process begun? I contemplated notions of redemption and forgiveness that echoed within the two triangles: one of Vasily, Bella, and myself and the other of our three grandfathers. On that evening, in the northern Israeli city of Haifa, we—the three grandchildren—discovered that grace can transcend antipathy and lead us to compassion and presence.During the next 3 months, Vasily struggled with a deterioration in his QOL, with the development of ascites, cachexia, appetite loss, fatigue, and pain. Despite his condition, Vasily attended weekly appointments with Bella. Five days prior to his death, I found Vasily nestling in the treatment bed for an hour and a half following Bella''s gentle massage. “I just want to remain in bed, I feel this is the safest place for me,” he replied on seeing my wondering look. At our next staff meeting, Bella and I discussed our feelings about the empty slot in the appointment schedule where Vasily’s name was supposed to appear. We wondered how the joint therapeutic process we had experienced with Vasily, during which our three remembrances had been unveiled, had led to a process of redemption and forgiveness. Vasily, in experiencing a safe place, confidence, and trust, had enhanced our own sense of compassion and guided us through a transforming journey of professional and individual growth.     

Information needs and decision-making preferences of children with cancer

Surveys discussing information needs and decision-making preferences were administered to 50 children with cancer (ages 8–17) and 60 accompanying parents. Children wanted information on all aspects of their disease and its treatment, particularly prognosis. 76% of children wanted to be told a percent chance for cure, no matter what it was. Only 38% of parents wanted their children to be given this information (p < 0.01). 95% of patients wanted to be told if they were terminally ill. The majority felt that the treatment decision was the physician's. Although 96% of patients did not want to make their own decisions about curative therapy, 63% of adolescents (≥13) wanted to make their own decisions about palliative therapy vs. 28% of younger patients (p = 0.018). Patients felt that people should be allowed to make decisions about participation in medical research at age 14, for treatment of minor medical problems at 16, and to refuse potentially curative therapy for cancer at 17. Parents often want to shield their children from adverse information, but most children want to be fully informed about their disease. Children usually do not want to make decisions about their initial therapy, but many feel that they should decide about palliation.