Integrative Palliative Care: Between Antipathy and Grace

Abstract

The author reflects on the therapeutic journey of developing a patient-centered care program aimed at relieving the patient’s concerns and improving his quality of life and well-being.

As a family physician responsible for managing an integrative oncology clinic in the northern Israeli city of Haifa, I have encountered many challenges in how I communicate with my patients. Patients referred to the integrative oncology service, operating within a conventional oncology service, come from a wide variety of cultural backgrounds and health beliefs. For the past 6 years I have worked in a full-time capacity as an integrative physician, following extensive training in supportive care and a number of complementary and integrative medicine (CIM) modalities. Our integrative oncology team includes 15 trained integrative oncology practitioners, including two registered nurses whose mission is to improve patients’ well-being during the difficult process of anticancer treatment.

Patients are referred by their oncologist, nurse oncologist, or psycho-oncologist to an hour-long consultation with the integrative physician who explores the patient’s narratives, expectations, and needs and tailors a patient-centered therapeutic program. The initial patient assessment and ensuing weekly CIM treatment sessions may include acupuncture, guided imagery, touch therapy, or guidance regarding nutrition and dietary supplements. The integrative therapeutic process also entails a sense of being, of contemplation—of providing an open space that allows me to meet the other.

For the past 2 years I have worked every Sunday with Bella, an oncology nurse with training in manual Chinese medicine treatments. Bella joined our integrative team with a passion for touch therapy. The weekly CIM encounter with patients exposes us to their suffering but also to their joy when attaining a good result from our treatments. During these interactions we often find ourselves meeting not just the other (i.e., patients and caregivers) but also ourselves. This delicate moment introduces us to our own narratives, as can be seen in the case of Vasily.

Vasily, a 51-year-old married man living in a small town in northern Israel, was admitted to the oncology service with a diagnosis of metastatic prostate cancer. He began anticancer treatment with bicalutamide (Casodex; AstraZeneca, Wilmington, DE, http://www.astrazeneca-us.com), goserelin acetate (Zoladex; AstraZeneca), and zoledronate (Zomera; Novartis, Basel, Switzerland, http://www.novartis.com) and was referred by his oncologist to the integrative oncology center for consultation. The stated reason for the referral was Vasily’s intention to take a dietary supplement, which his oncologist asked me to check for safety and efficacy. At our first encounter, I was impressed by the patient's kind facial expression. Vasily had only a basic level of Hebrew, despite living 15 years in the country after emigrating from the Republic of Belarus. Despite the advanced stage of his disease, Vasily continued his daily work at a family-run grocery shop, where he worked with his wife and two children.

I began the consultation by asking Vasily about his expectations regarding the integrative medicine consultation. Vasily was direct and clear: he expected me to advise him on the value of the homeopathic remedy Conium maculatum for treatment of his prostate cancer. The herb in question, popularly known as hemlock, is extremely poisonous, although the homeopathic form has undergone numerous dilutions and contains negligible quantities of active components. Acknowledging Vasily’s expectation that I focus on the curative potential of the homeopathic remedy, I suggested that we explore additional concerns related to outcomes for quality of life (QOL). Vasily revealed that he had been suffering from fatigue and hot flashes that were significantly impairing his daily function. At the end of our first conversation, we jointly agreeing to define two integrative treatment objectives: providing a recommendation regarding the curative role of the homeopathic remedy Conium maculatum for prostate cancer and providing a CIM treatment regimen to reduce his symptoms and improve his overall QOL. A follow-up appointment was scheduled, and Vasily was referred to one of our integrative nurses for CIM treatments.

After my encounter with Vasily, I searched the medical literature for any evidence of effectiveness and safety of homeopathic Conium, primarily with respect to prostate cancer. Surprisingly, a PubMed search found two in vitro studies on Conium and prostate cancer cell proliferation, although neither revealed beneficial effects [1, 2].

At our next conversation, I showed him my findings, and we agreed to focus on his symptoms, which were related to the hormonal treatment. The literature contains several studies supporting the use of acupuncture [3] and sage (Salvia officinalis) [4] for reduction of hot flashes and of acupuncture and acupressure for cancer-related fatigue [5]. During the weeks that followed, Vasily attended weekly 30-minute sessions of manual therapies (tuina and acupressure) provided by Bella, our integrative nurse. Occasionally I would treat him with acupuncture. His symptoms improved significantly, as did his sense of well-being. This improvement was also evident by Measure Yourself Concerns and Wellbeing (MYCAW) [6] scores at 6 weeks compared with the initial assessment, with decreases from 4 to 1 (on a scale of 0 to 6) for hot flashes and from 4 to 2 for fatigue.

At his 30th treatment follow-up visit, Vasily was reassessed by Bella, who reduced treatment frequency from weekly to biweekly. I had asked Bella to present Vasily’s case at our weekly staff meeting, and she was eager to provide an in-depth understanding of the integrative care experience. Her next discussion with Vasily was open and informal, involving no assessment questionnaires. Vasily informed Bella of his satisfaction with her devoted care, especially considering that the CIM treatments took place in the very same department where the chemotherapy was being administered. He told Bella about his emigration from Belarus to Israel, as a Christian married to a Jewish wife, and of his decision to undergo circumcision. He then told Bella of his vivid memories of his grandmother, brutally murdered by Soviet soldiers after the liberation of Belarus as an act of revenge. His grandfather had been an employee of the German Gestapo during the war. Despite the gravity of this revelation, Bella continued the interview, at the end of which she thanked him for trusting and confiding in her by sharing this secret.

It took Bella and me several days to process our feelings about Vasily’s unsettling revelation, although we shared admiration for his courage in disclosing his grandfather's story. Bella told me her own story, of her grandfather who had fought and died during World War II as a Soviet soldier fighting the Germans. And I could not avoid the memory of my own grandfather who had served in a Jewish unit of the British army and was captured by the Germans in Greece in 1941, along with hundreds of other Jewish soldiers recruited in Palestine for His Majesty's Army. On his way from Greece to a prisoner-of-war camp in Europe, my grandfather witnessed SS Reichsführer Heinrich Himmler ordering his officers to treat Jewish prisoners in the same fashion as captured British soldiers and not as “ordinary” Jews. Crossing the Corinthian Canal, my grandfather recalled his passage 3 years earlier, from the western bank of the canal to the east on his way from Lithuania to Israel. My grandfather and his fellow Jewish British war prisoners were eventually transferred by the Nazis to a series of labor camps in Eastern Europe. From there they were forced to march, between 1944 and 1945, more than 1,000 km westward with the retreating German forces, where they were eventually liberated by the American army.

Contemplating our intertwining stories—Vasily's, Bella’s, and my own—I envisioned the unlikely event in which our three grandfathers met, just as their grandchildren were doing now: one a Gestapo agent, another a Soviet soldier, and the third a Jew in the British army corps. We were all third-generation descendants of the tragedy of World War II, each with our own historical narrative. What was it that led Vasily to reveal his secret, leading to this interaction among the three of us—a situation unimaginable to our forefathers? Could it be his encounter with a life-threatening illness or perhaps his gratitude for our treatment that encouraged him to open up? Was it a sense of coherence and containment provided by Bella, who had touched him both spiritually and physically?

I began to rethink my own role as a dually trained physician, in family and integrative medicine, who at times experienced being rather than practicing doing. I closed my eyes, allowing myself to greet mindfulness. How had this process begun? I contemplated notions of redemption and forgiveness that echoed within the two triangles: one of Vasily, Bella, and myself and the other of our three grandfathers. On that evening, in the northern Israeli city of Haifa, we—the three grandchildren—discovered that grace can transcend antipathy and lead us to compassion and presence.

During the next 3 months, Vasily struggled with a deterioration in his QOL, with the development of ascites, cachexia, appetite loss, fatigue, and pain. Despite his condition, Vasily attended weekly appointments with Bella. Five days prior to his death, I found Vasily nestling in the treatment bed for an hour and a half following Bella's gentle massage. “I just want to remain in bed, I feel this is the safest place for me,” he replied on seeing my wondering look. At our next staff meeting, Bella and I discussed our feelings about the empty slot in the appointment schedule where Vasily’s name was supposed to appear. We wondered how the joint therapeutic process we had experienced with Vasily, during which our three remembrances had been unveiled, had led to a process of redemption and forgiveness. Vasily, in experiencing a safe place, confidence, and trust, had enhanced our own sense of compassion and guided us through a transforming journey of professional and individual growth.

Disclosures

The author indicated no financial relationships.