One of the most difficult consultations of all, for both the doctor and the patient, follows the unarguable failure of management so far. For the doctor it may feel like a personal defeat and for the patient a personal disaster. Doctors hate to admit failure which flies in the face of their whole professional endeavour.
Most of us, as patients, simply cannot accept the dire implications of reaching the end of the road. The temptation for the patient, and often for the doctor also, is to find some glimmer of hope in yet another form of treatment. However, an honest conclusion may be that any treatment at this stage is likely to do more harm than good. For example, if chemotherapy type one (which was the most likely to be effective) and chemotherapy types two and three (which had very little chance of success when chemotherapy type one has failed,) have all proved futile then yet another treatment is exceedingly unlikely to benefit the patient. It may be better to discontinue active treatment and turn to supportive care. Quality of life is likely to improve in the short term. There will be no new side-effects and fewer visits to the hospital. Supportive care, it must be emphasised, is not the absence of care but an active process of symptom control and thoughtful planning.
It takes courage on the part of the doctor to carry this decision through, (and I am sorry to report that some doctors do not manage it) and above all courage on the part of the patient to accept the reality.