Intended for healthcare professionals

Rapid response to:

Practice What Your Patient is Thinking

Don’t torment me with hope

BMJ 2020; 370 doi: (Published 09 September 2020) Cite this as: BMJ 2020;370:m3016

Rapid Response:

Re: Don’t torment me with hope

Dear Editor

In defence of hope

Alexandra Filby’s painful experience illustrates the need for more open and upfront, albeit difficult, conversations about prognosis and death. [1]. The society, as a whole, doesn’t embrace death in a rational manner and oncologists are no exception. [2]. As observed in an ethnographic study, doctors and patients do sometimes collude in avoiding discussions about death.[3].

Nevertheless, honest conversations about death don’t mean extinguishing hope when discussing treatments for incurable disease.[4]. This is because hope helps to dissipate anger and frustration. Hope keeps the cloud of despair at bay as the painful journey progresses towards acceptance of death.

Along with discussions about prognosis, many patients do prefer “cup half-full” type of hopeful honesty rather than “cup half-empty” type of dark pessimism. Many cancer patients go through palliative chemotherapy for small survival benefits even after an open honest conversation about benefits and risks.[5].

Furthermore, Oncologists are not terribly good at accurate prognostication.[6]. Not all cancers behave in the same manner. Some cancers are quite aggressive. Some can be indolent. Some respond well to treatment. Prognosis of advanced cancers is actually quite dependent on response to treatment. An incurable cancer diagnosis doesn’t always spell doom and gloom as exemplified by advanced prostate cancer patients having a prognosis typically measured in years. So when there are significant uncertainties about anticipated treatment outcome, hoping for an optimistic outcome is the default coping mechanism of many patients as well as their oncologists.


1 Filby A. Don’t torment me with hope. BMJ 2020;370. doi:10.1136/bmj.m3016

2 Enkin M, Jadad AR, Smith R. Death can be our friend. BMJ 2011;343. doi:10.1136/bmj.d8008

3 The A-M, Hak T, Koëter G, et al. Collusion in doctor-patient communication about imminent death: an ethnographic study. BMJ 2000;321:1376–81. doi:10.1136/bmj.321.7273.1376

4 Kirk P, Kirk I, Kristjanson LJ. What do patients receiving palliative care for cancer and their families want to be told? A Canadian and Australian qualitative study. BMJ 2004;328:1343. doi:10.1136/bmj.38103.423576.55

5 Slevin ML, Stubbs L, Plant HJ, et al. Attitudes to chemotherapy: comparing views of patients with cancer with those of doctors, nurses, and general public. BMJ 1990;300:1458–60. doi:10.1136/bmj.300.6737.1458

6 Glare P, Virik K, Jones M, et al. A systematic review of physicians’ survival predictions in terminally ill cancer patients. BMJ 2003;327:195. doi:10.1136/bmj.327.7408.195

Competing interests: No competing interests

19 September 2020
Santhanam Sundar
Consultant Oncologist
Nottingham University Hospitals NHS Trust