Goals of Care in Later-Stage CRC


John L. Marshall, MD: So, when you as a patient first came in with metastatic colon cancer, if you’re like most folks, you really wanted to be aggressive. You wanted to do every treatment you could and you want to be cured of your disease. We absolutely get that. And, often, our initial strategy is to be more aggressive, to treat that cancer and to get it to shrink down and reduce symptoms. Then, our next goals are to try and maintain that as long as we can. In my way of thinking, it’s not how much chemotherapy or treatment I can give, it’s actually how little I can give and keep that down.

When you first come in with your doctor, I think most folks have what we call a “goals-of-care” discussion on the first visit, or a discussion on where are you in life, what are your priorities, how aggressive do you want to be, what are your support systems, etc. And then, you are in the groove with treatment and that conversation falls off. But, as you go through the different lines of therapy, I think there are nice, natural moments to re-talk about this. I was just thinking that patients often hesitate to bring this up to us, but we’d like to talk about it more. So, what advice would you give to a patient as they go through these so-called goals of care, or advice on overall desires for the patient?

Monica Chacha, RN: One of the most important things that I tell people is just to be open and up-front with what they want in their care. I think a lot of times people are nervous to really be open and honest with the nurse or with the doctor, but really they’re the ones that make this decision.

John L. Marshall, MD: And, if you could wish something that all your patients would come and ask you, or that they did better, what kind of advice would you give them to help our interaction?

Mohamed E. Salem, MD: I agree with Monica. I think it’s very important and valuable to us when patients tell us what they want and what is really important for them because maybe what’s important for me is not the same thing for them. And it’s not just for patients, I think it’s important to include their family members as well: their spouses, their kids, and loved ones. I think it’s not just a diagnosis for one person, it’s the whole family.

John L. Marshall, MD: And we often notice, just to warn everybody, that there’s a disconnect. I think patients out there want one thing: they want to be cured of this disease. And the reality is we can do better, but we can’t necessarily cure folks. So, what we’re trying to do is get more information from them. In that context, in that bad news that you’ve got a bad disease, what are the important parameters that you have? And we have all sorts of patients: patients who want to be treated until their last day and patients who actually think about it and say they’re tired of getting CAT scans and labs. That’s all okay, right?

Mohamed E. Salem, MD: It is. In fact, I just saw one of my patients yesterday in the clinic and she told me, “The most important thing, for me, is to play golf.” That’s what she likes, and we had to adjust the treatment schedule, the dose, and even the therapy we give to allow that as much as we could.

John L. Marshall, MD: Yes. And I know we’ve had many patients where they might not tell me, but they’ll come and tell you on a phone call later. We’re talking all the time.

Monica Chacha, RN: Absolutely.

John L. Marshall, MD: So, goals of care are always important to be discussing with your team. We’re listening. We’re here. We’ll try to do our best to meet those goals.

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