Special Report Compassionate Honesty Charles L. Loprinzi, M.D., 1 Lidia Schapira, M.D., 2 Timothy Moynihan, M.D., 1 Gregory P. Kalemkerian, M.D., 3 Charles von Gunten, M.D., Ph.D., 4 and David Steensma, M.D. 1 Introduction P atients with cancer comprise 40%–100% of patients seen by those working in hospice and palliative medicine around the world. Consequently, the skills of oncologists in integrating palliative care and making appropriate referrals for hospice care have been a subject of intense interest since the inception of the field. Most are aware that oncologists routinely assist patients in making difficult decisions, at the time of initial cancer diagnosis and for months or years thereafter. Such discussions involve imparting the news of a new diagnosis of cancer or a recurrence, providing results of day-to-day tests or staging scans, and addressing prognosis. Typically, the most difficult discussions are those that address the lack of effective medical treatments. Although they are aware they should do this in a compassionate and sensitive manner, most had no specific training or feedback on how to do this. Yet, these are precisely the issues of most concern to those in hospice and palliative care. In recognition of these facts, the Journal of Clinical Oncology initiated a series written primarily by and for oncologists that addresses this area. 1 Called, ‘‘The Art of Oncology,’’ the series aimed to publish direct and meaningful reflections to help oncologists in their practices. The Journal of Clinical Oncology is the most high-impact journal serving oncologists in the world; what it publishes is noticed. The readership of the series has been high. Professionals in palliative medicine will want to know of this series for at least three reasons: (1) it gives insight into how oncologists think about the issues; (2) it gives advice that oncologists have given to oncologists about how to deal with these issues; and (3) each can be used as a way to stimulate discussion with oncologists in your area on which to build better relationships. Tell the Truth Conversations about expectations of recovery, time frames, and hope for a normal future are extremely important for patients with cancer and their loved ones. A common senti- ment among many oncology professionals is the need to nurture hope in their patients. Many colleagues are afraid of causing harm by forthrightly addressing issues of prognosis when the outlook is grim. This is only normal, as is the desire to protect patients from harm or disappointment. It is easy to imagine situations where the doctor means well and avoids addressing important issues out of a genuine desire to protect his or her patient. In the article ‘‘Setting Goals to Maintain Hope,’’ Von Roenn and von Gunten provide a strategy to direct physicians in their approach to honest, yet hopeful, disclosure of a poor prognosis. Teaching patients to reframe the object of their hope, and setting realistic, short-term goals allow the oncologist to engage in a dialogue that focuses on life, instead of avoiding the topic altogether. 2 ‘‘Sign-posting’’ provides valuable clues to a patient and his loved ones that they have entered into a new and perhaps unfamiliar or frightening territory. As noted by the authors, if a person is driving on a highway, it is appropriate to have warning signs to alert drivers as to when the exit is approaching. In a similar fashion, patients and their loved ones need some warnings from the doctor that signal that a change has occurred or that the end is near. Smith 3 provides a clear and logical strategy for helping clarify goals and plans of care in the piece entitled ‘‘Tell it Like it is.’’ He advocates the use of a written document in which the doctor and patient record important information about the disease, intention of treatment, and emergency contacts. This straightforward approach can be adapted to other situations and serve as a model for clarity and partnership between patients and their professional caregivers. ‘‘Caring for Dying Patients: What is Right?’’ 4 describes the consequences of the all too familiar situation whereby patients with advanced incurable cancers are not told the truth about their condition. They are sent home ‘‘to try to get stronger so that they can become fit enough to receive chemotherapy.’’ The frequent consequence of this scenario is that an ill patient comes back to an emergency department with a life-threatening event. Without the patient and family’s ap- propriate understanding of the situation and possible com- plications that might occur, they are left to struggle alone without the professional guidance required to sort through difficult treatment choices. This raises one of the central issues of the patient-oncologist relationship, namely to ask and consider if the one and only business of this relationship is the 1 Mayo Clinic, Rochester, Minnesota. 2 Massachusetts General Hospital, Boston, Massachusetts. 3 University of Michigan, Ann Arbor, Michigan. 4 Center for Palliative Studies, San Diego Hospice, San Diego, California. Accepted July 19, 2010. JOURNAL OF PALLIATIVE MEDICINE Volume 13, Number 10, 2010 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2010.9777 1187