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For even the most compassionate physician, discussing end-of-life care with a patient when their cancer is no longer responding to treatment can be challenging. This conversation is even more difficult when it cannot take place in person, a common occurrence since the onset of the COVID-19 pandemic.

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UNC Lineberger’s Hanna Sanoff, MD, MPH.

In an essay published in JAMA Oncology, Hanna Sanoff, MD, MPH, clinical medical director of the North Carolina Cancer Hospital and a member of the UNC Lineberger Comprehensive Cancer Center, said she was unprepared to speak of death and dying with patients via web conferencing or the telephone.

“I’ve not yet figured out how to help guide my 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,” Sanoff said. “What does it take, to find balance and connection in virtual oncology?”

Quality of life challenges during pandemic

The widespread implementation of stay-at-home orders had another downside for terminally ill patients and their family members and friends; the travel restrictions intended to reduce the spread of disease also prevent patients from taking a final trip to a special place.

“My patients are losing the time our society had promised them with our talk of bucket lists and choosing quality of life,” said Sanoff, who specializes in the treatment of gastrointestinal cancers. “It’s pretty horrible. People are struggling to figure out how to see their families and enjoy the things they like to do. It’s very demoralizing (for them) to have to just stay at home all the time.”

For all of the challenges of caring for her patients virtually, Sanoff has seen an upside. She has found it is easier to address issues beyond treatment that are distressing her patients, including physical disabilities, financial strain and food insecurity.

A physician sits at a desk and works on a laptop. They are holding a stethoscope in one hand and a stylus in the other hand to work on the laptop.Increased use of telemedicine

She also anticipates the pandemic will be a long-lasting health concern and, with that, she accepts that growing reliance on virtual care will affect how she and her patients interact.

“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,” Sanoff said. “[F]or my patients at the end of life, I’m 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.”