“By the way doctor, I’ve booked an African safari after my next chemo”
BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.g7822 (Published 06 January 2015) Cite this as: BMJ 2015;350:g7822
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"But perhaps the main concern for doctors is that the extra work involved in preparing such patients for travel can be substantial."
Professor Epstein's article also strikes a chord with those of us on the receiving end of the traveller whose finely balanced medical condition suffers a meltdown in a remote area. Every dry season, our little hospital experiences a nearly three-fold increase in attendances by elderly people:
http://www.smh.com.au/national/health/bucket-list-tourism-grey-nomads-tr...
A percentage of these are people who become critically ill in ways that could probably have been foreseen as likely, especially given the punishing nature of our climate, even in the dry season. Many do not take out travel insurance, no doubt for reasons of difficulty, as rehearsed elsewhere on this thread, and also because the destination is still in Australia. With an air ambulance flight from Broome to the Eastern states of Australia costing $75,000 or more, that can be an expensive mistake.
The ease of travel today and the instantaneous nature of modern communications, combined with an expectation of the same delivery of service wherever you go, can lull patients into a false sense of security. We have a small hospital with limited facilities and there is no escaping the fact that our referral hospitals in Perth are over 1,700km away by the single-engine, turboprop lifeline of the Royal Flying Doctor Service.
We all want to see Broome, but patients and their treating physicians need to be realistic and ensure they come and see Broome before they die, rather than see Broome and die.
Competing interests: I am one of the doctors who treats visitors to a remote area who present with a decompensation of their chronic or terminal illness.
I have to agree with the response by David K Woolf, that obtaining travel insurance is a major barrier and a significant task. My experience, although thankfully not following diagnosis of terminal cancer, was surprisingly challenging. I consulted a number of agencies that claimed to be experts and specialists in offering insurance for patients recently treated or currently undergoing treatment for cancer. Over a period of 3 months to 15 months following my treatment (surgery and chemotherapy), for a curable cancer with good prognostic outcomes, I was unable to secure travel insurance. All the treatment was completed, I took no medication, had normal bloods and follow up tests throughout this period and at the age of 30, no other past medical history. My trip to Europe in the months prior to diagnosis (ironically accompanied by a rather large tumour) had cost me £7 in insurance.
I contacted no less than 10 companies with such specialist. All but 3 refused to offer me any kind of cover. The cheapest of the remaining (and even then only 12 months after treatment) was in excess of £700. During this time I was working full time, ran a marathon and even had a baby. I spent a large amount of time trying to get to the bottom of why I was so utterly uninsurable, which led to immense frustration and upset. I missed holidays and weddings, but true, I had my health. Yet perhaps there a feeling of what am I missing? My doctors are telling me I am well, to get on with life, yet why do these companies feel I am such a risk?
Mainly, frustration came from an-ever repeated scenario which went something like this:
“Madam, what kind of cancer are you diagnosed with? … “oh, that’s not on our system. I’ll just put ‘cancer, other’. Did is spread?” Me: “Yes, local spread”. “Ok, so metastatic cancer; was it your brain, lungs, or bones that it spread to …” Attempts to explain to the call centre operator that local invasion is not the same as metastasis and that none of this rather limited list of organs was involved, invariably led to a response of “computer says no”. On one occasion, a more flexible system allowed me to bypass the hitherto insurmountable metastasis question, when I was confronted with the blasé monotone request: “Is it terminal and if so how long have you got to live”. And these are the specialist agencies!
On the plus side, this was an excellent opportunity to explore the United Kingdom and even honeymoon on a canal boat in the beautiful Welsh countryside! I was incredibly fortunate that I wasn’t seeking a “life affirming” trip with a terminal illness, but I can’t imagine the mindset of such a patient who is confronted with a minefield of ill-thought out and, at times, insensitive questions.
Competing interests: No competing interests
Epstein hugely underestimates the difficulties many patients with metastatic cancer have in arranging “a life affirming trip abroad”. At a time in their life when these trips take on a special significance, a high proportion of patients struggle to obtain travel insurance. Companies that have happily taken their customers money for many years now either decline insurance altogether or quote astronomical premiums into the thousands of pounds and normally in excess of the cost of the holiday itself. The process patients have to manage involves negotiating the litany of intrusive questions fired at them by anonymous call centre operators only to have to start again once an unaffordable premium is offered. When asked for help most oncologists usually shrug their shoulders and mutter about the immoral behaviour of insurance companies.
Competing interests: No competing interests
The needful rather than the wishful
Dr Epstein's article, and the other responses here make valid points about paperwork demands on doctors, issues around insurance, and the stress potentially put on medical services in destination locations.
I don't want to underestimate the importance of these.
But I do want to query the last sentence of Dr Epstein's article. He talks about "the needful, rather than the wishful": but surely palliative chemo is often - perhaps even always - more about the wishful than the needful? Of course, there are exceptions to this - for example when specific pain symptoms are being treated.
But isn't the whole point of palliative chemo to allow the patient to have more time or, more hopefully, more good-enough time?
And isn't the latter just what a holiday is all about too?
Dare I even ask about the treatment before the holidays? The treatment the patients are wanting a break from. Dr Epstein mentions the "litany of toxic treatments" which he describes as has having "valid but underwhelming statistical benefits". I wonder if the doctor-patient communication is always as honest about this as is suggested to be necessary when the patients want to do something potentially hazardous. I especially mean communication about the uncertainties of any real gain from the treatment.
Of course it's true that you can't always get what you want - but I wonder if some oncologists might also consider sometimes applying that idea to themselves and their potentially hazardous treatment decisions? Or are they sometimes guilty too of investing in temporary periods of optimism and positivity for its own sake?
Competing interests: My dad wanted to go skiing during his palliative chemo