A few years ago, while working as a palliative care physician, I treated a man in his 60s who had been fairly healthy before being diagnosed with stomach cancer. After three lines of treatment had failed, my oncologist and I told him that a fourth treatment might, at best, add a few weeks to his life. “Let me go back to Boston,” the man said immediately. He wanted to smell the Atlantic Ocean and see his childhood home. He made it to Boston, and died a week later.
My patient died on his own terms, in full knowledge that his cancer was worsening, in peace, and able to decide where and with whom he wanted to die. This is the type of “good death” that our health care system is increasingly striving for, but not necessarily for the young.
In the hospital room next to this man was a young mother, also in her 30s. We bonded over our love of ’90s music and the Southern California beaches where we built sandcastles as kids and stayed out late as teenagers. She, too, was dying of stage 4 stomach cancer. I first met her when her oncology team asked me to help them manage the pain and nausea. She had her hands pressed against her protruding abdomen, bloated with fluid and gas because cancer had blocked her intestines. Unable to eat, she was receiving medication and liquid nutrition dripped through a large catheter threaded through a vein in her arm to her heart.
Like her elderly neighbor, she had undergone a variety of treatments, none of which worked. But when she asked her oncologist how long her next round of medications would buy her, I remember him encouraging her to stay positive, telling her he didn’t have a crystal ball to tell her the future. She’d made it through other tough treatments and still had hopeful options. Her husband reminded her that there was much to live for.
These conversations are happening every day. More young Americans than ever before Dead Diagnoses of cancers common among older adults are on the rise Most rapidly Among those in their 30s. Millennials Born in 1990— The pinnacle of a generation—They are twice as likely to develop colorectal cancer as baby boomers born in 1950. Younger adults are likely to be diagnosed with cancer at a more advanced stage and suffer more from the disease. Aggressive Tumors are more likely to develop in older adults. In caring for these patients, I have seen how a patient’s age affects how the medical team and family view them, the treatment choices they want for them, and the silence surrounding their mortality. A patient’s youth can be a justification for pursuing physically devastating and sometimes ineffective treatments. The unspoken assumption is that they want to live as long as possible, regardless of quality of life.
My patient knew that her cancer was incurable, and that each time a treatment failed, the next one would likely be harsher and less effective. Whereas she had once found comfort in the possibility of further treatment, she now feared it would only exacerbate her daily suffering. But even as her cancer progressed, both her doctors and family were hesitant to discuss her inevitable death and how she wanted to spend the rest of her life.
Young adults face unique stressors after a cancer diagnosis. They may worry about being able to have children or see them grow up. They may not be able to get stable health insurance or finish school. They may also have to face sudden anxiety and grief as they watch their peers move forward professionally and in their relationships. While physicians’ efforts to accommodate these losses by delaying emotional conversations may be well-intentioned, that instinct hurts younger patients in another way: by depriving them of information and options that are readily available to older patients.
and young patients want Patients are given information about their prognosis and the opportunity to share how they would like to be cared for at the end of their life. Without these discussions, many suffer avoidable situations, such as dying in an intensive care unit instead of at home, and doctors are left with no choice but to accept the consequences. Overtreat Younger people are given harsher and sometimes unproven treatments that are not as readily available to older patients, and these treatments only help younger people survive slightly longer.
My patient’s oncologist believed her body and healthy organs could withstand the toxic treatments. The question of whether she could tolerate, let alone enjoy, the life she had was secondary. Just because most of her organs were still functioning did not mean that she would want further treatments or that further treatments would help her live the life she wanted.
Still, her family wanted to give her every chance. She struggled to play with her son, and he only watched her when she was sick or sleeping. “What chance?” she asked me, pointing to her bruised arm and a trash can full of vomit. She longed for freedom from hospitals and chemotherapy rooms. She wasn’t sure if she should want it.
Doctors’ own understandable feelings can sometimes delay such discussions. He talked about Physicians may avoid initiating painful conversations because they love their patients and do not want to cause them pain or harm, only to find that this delaying tactic ends up causing more pain later. Many physicians Deep feelings of guilt and failure When are they Can’t save the lives of young patients.
But getting older cannot stop the progression of stage four cancer, nor can it change the fact that at some point treatment will no longer work. Just acknowledging that the patient is dying felt sinful. But when someone in their 80s is dying, there is often an unspoken, and sometimes verbal, feeling that they have lived a full life, that death is natural and expected, and somehow less tragic and easier to deal with.
But what is a fulfilling life? How do we know that a younger person is not living a fulfilling life, or that an older person is? To help people find that fulfillment, physicians must ask what it means to them. Their answers will reflect who they are, what matters to them, and how they want to spend the time they have left. These are important conversations to have with every patient. Many people of all ages will be forced to accept aggressive treatment as a given or will face death in circumstances they do not want. As the number of young cancer patients continues to grow, physicians who accept their obligation to have honest, compassionate conversations with every patient can help them make choices that reflect their humanity.
I, too, struggled to see beyond my patient’s age. It was easier to talk about the mixtapes I made in high school than to address the reality of her illness. But as she deteriorated, I realized that avoiding that reality was only protecting me, and that my silence might rob her of the precious moments she could spend with her family. To provide good care, I had to learn the difference between my own suffering and hers, and how focusing on my own emotions limited my ability to understand hers.
It can be difficult to know how to begin a conversation about death with someone in their 20s or 30s. Voicing your choicesan advance care planning guide developed for younger patients, presents gentle questions that may be helpful in early discussions. In addition to presenting common questions about treatment choices and identifying surrogate decision makers, the document encourages health care providers to ask how patients would like to be comforted, how they would like to be supported when they feel lonely, how they would like to be remembered, and what they would like to be forgiven or forgive others for. These questions reveal who the patient is and what they value. This is information that will shape the patient’s choices, regardless of age or diagnosis. Understanding who will be making the decisions can help families and physicians feel more comfortable accepting the person’s choices, whether they choose the most aggressive treatment until the patient dies or an intervention that will minimize suffering.
The next time the oncologist and I met with the patient, he asked if further treatment was worth it. Whatever the choice, the oncologist told him he probably only had a few more weeks to live. The patient’s face softened. Like the patient in Boston, he seemed relieved to hear aloud what he already knew to some extent. The patient did not want further treatment, and he and his family, craving privacy, were not emotionally prepared for him to be placed in a home hospice with regular medical professional visits. The patient elected to continue only medications for nausea and pain for the time being, intending to return to the hospital if other needs arose.
Before we left, she told me what she was looking forward to: drinking lemonade even if it made her puke, sleeping in her own bed, and searching for the stars outside her window with her son, even if they were only slightly visible in the winter haze.
