Constraints imposed by coronavirus disease 2019 (COVID-19) have changed every part of my life, but disruption of human connection with patients has been the most unsettling to me. Over 15 years as a gastrointestinal medical oncologist, I have learned from patients how to help them through terminal disease, attended workshops on how to speak about the end of life, and strived to share in patients’ grief without losing myself. But I find myself wholly unprepared to speak of death and dying across cell phones or video links with unreliable connections. I have not yet figured out how to help guide patients’ struggles with cancer—leading them toward a death with dignity and finding personal reward in our relationship—when I cannot see them, hug them, or see their love for each other. What does it take to find balance and connection in virtual oncology?
Like all gastrointestinal oncologists, I have had the conversation so many times before: “Unfortunately, the chemotherapy is no longer working. We no longer have any options that offer a meaningful chance of controlling the cancer. We’re in a different place with your cancer now.” Though the words are similar, each of these experiences differs, shaped by the emotional response of the individual receiving this news. In our usual venue of face-to-face visits, I am able to see and feel these responses fully. I have seen the beauty of a sad but peaceful acceptance of the end of a life well lived, imbued with hope for some joy yet to come. I have seen anger, denial, and the lashing out that comes with unfathomable distress. And sometimes I have seen a grief so profound in the face of horrifying loss of love that I can hardly bear witness to the depths of the patient’s sorrow.
It was into this sorrowful depth that I stared yesterday, in the new, unsettling format of a video visit. Unsure of how to proceed, I started by acknowledging the inadequacy of our virtual interaction, and how I wished we could meet in person. I then shared the news of pancreatic cancer progression with my kind-hearted patient who loves life, who feels love and laughter—and pain and sadness—intensely. And I shared it with her gentle, spiritual, loving wife. From afar I watched grief overtake them, gutted by sorrow for the loss of a love so deeply shared.
From my laptop screen, I also saw how COVID-19 has brought new losses to the terminally ill who now grieve for what stay-at-home orders have taken away. This couple lost their final trip to “their place”; they will not get their bittersweet final swim in the warm Caribbean. Patients with terminal cancer are losing the time our society had promised them with our talk of bucket lists and choosing quality of life. They are mourning their death and trying not to rage at the arbitrary injustice of a premature loss of love’s shared joys.
And, like this couple, some also grieve the loss of their connection to their oncologist. So much of my job is about developing relationships, learning about what matters to patients, who they love, and what they hope to do with whatever time may remain. This friendship and trust, I hope, helps them through difficult decisions. And our continued connection once active treatment is exhausted seems to provide some comfort as they near the end. Instead of that comfort, people now ask me if they will see me again before they die.
Until now, in my years as an oncologist, I have not been broken by the sadness in which I share. Rather, I find the sadness is balanced by getting to share in the best of people as they support each other in the rawness of loss. I receive ample reward in the form of kindness I witness and receive. And as a cancer physician, I have met, cared for, and cared about people I would have never known. I have mourned pro-gun, Trump Republicans that the world tells me this Quaker-educated liberal Yankee never could befriend. I have shared in the stories of old tobacco farmers, young mothers and fathers, and veterans whose shadows of war dog them throughout their cancer journey. This outpouring of kindness and this privileged sharing of humanity have helped me believe that what I do matters and helped me share in patients’ grief without losing myself.
But yesterday, I was staring at this, well, this abyss of loss. And the video visit brought me none of this connection that sustains me. This time I spoke with these women, who have gifted me such love, through the technological challenges of freezing screens and an ad hoc land-line audio feed. In this video format, I found myself ill prepared to speak the words I have spoken too many times. I was uncharacteristically at a loss for words. And uncharacteristically on the verge of tears. I did not know how to help guide them through their profound sorrow when I was so disconnected from their humanity. If together, I would wait through the tears, I would let them hold each other, and I would hug them. And I would know better how to show them how I wish I could change their reality. I did my best, but it was awkward, and not nearly enough for them or for me.
Virtual oncology is not a field I would choose. Yet I have begun to see glimpses of how we can maintain the human connection that drives medicine within the confines of virtual care. This is easiest with the patients I have known for years. I find us laughing more now. We laugh at the absurdity of our plight, and together, we look toward better days. With new patients, it is harder. My laughter often rings hollow, and I cannot tell if I am being kind or insensitive. And patients seem to ask fewer questions, as if they are less comfortable. But how could they be as comfortable? We have never met. But perhaps I am doing a better job than I think, as today in a televisit a patient with newly diagnosed cancer told me they would drive the many hours to a treatment center for infusions because they only trust me to oversee their care. And I notice it is easier to delve deeply into noncancer causes of distress—physical disabilities, financial strain, food insecurity—as if the anonymity of virtual medicine and the pressures of COVID have given me permission to ask things I always should, but sometimes feel uneasy doing.
COVID-19 will not retreat soon, so I must embrace virtual care. I am learning as I go, and so far, I find being open about the distress created by the format and the unusual manner in which our therapeutic relationship will unfold to be a good place to start. Laughter goes a long way. And, for patients at the end of life, I am scheduling more frequent visits, hoping that will provide them and me with the connection we need to carry us through our grief and loss in this era of COVID-constrained virtual care.
Corresponding Author: Hanna K. Sanoff, MD, Division of Oncology, Department of Medicine, University of North Carolina, 170 Manning Drive, Chapel Hill, NC 27599-7305 (hanna_sanoff@med.unc.edu).
Published Online: July 23, 2020. doi:10.1001/jamaoncol.2020.2839
Conflict of Interest Disclosures: Dr Sanoff reported grants from Bayer outside the submitted work.
Additional Contributions: We thank the patient for granting permission to publish this information.