Walking in the Valley of the Shadow of Death

As Interventional Oncologists, we live in the Valley of the Shadow of Death. Contrary to Psalm 23, there is plenty for the wise practitioner to fear. 

Most of our patients will succumb to their disease. That in itself is not to be feared; preparing our patients for death is part of our job. Atul Gawande’s Being Mortal and Paul Kalanithi’s When Breath Becomes Air are required reading for all Interventional Oncologists. 

Along that journey, we offer many interventions that are primarily palliative. We ask the patient to accept some risk as the tradeoff for a longer or less symptomatic life. 

So far this year I have had one fatality, one ICU transfer, and one 23-hour observation on the IO service that turned into a weeklong inpatient stay on the Hepatology service. All three were after palliative procedures that the patients and their referring physicians wanted, but were not absolutely needed. The risk:benefit ratio loomed large in our consultations.

Every major IO intervention carries some risk of a major complication or death, however small. No patient believes they will be among the unlucky few, but some have to be. I discouraged two of my patients from the requested intervention because of my concerns over the risk:benefit ratio, and after they expressed their desire to proceed made sure the other oncology team members agreed that the intervention was justified.

Senior faculty attract complex cases where both the indications and the risks may not be clearcut, and judgement based on years of experience acts in the absence of data. Our monthly M&M conference is a good opportunity to review cases where we do more harm than good, and get objective feedback from uninvolved colleagues. When a technical success turns into a clinical failure, the decisions leading up to the intervention deserve careful re-evaluation. It is critical that we not allow what we can do to overshadow what we should do. 

As we accompany our patients on their journey through the Valley of the Shadow of Death, it is inevitable that we will harm some of them. Living with that burden is part of being an Interventional Oncologist. The key is to learn from the experience and move on - the next patient is waiting. 

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