Whatever the moment … live every second and regain the memories of the wonderful things experienced and enjoyed day after day… knowing that life hangs by a thread.

One of the most important things in palliative cancer care, when patients are at the end of their lives, is to discuss the finiteness of life with the patient and their family caregivers. Therefore, it is necessary to work with and resolve personal disputes by reprogramming and restructuring the life that is ending.

The Barretos Cancer Hospital (Barretos, São Paulo, Brazil) has one unit that only deals with palliative care. Half of the patients hospitalized die during their admission. The interdisciplinary team works closely with physicians regarding appropriate therapeutic communication with patients and families, trying to redirect the focus of attention principally toward the person and that person's individuality and not toward only the disease, which in such cases is refractory to treatment.

In my routine as a physician of this institution, I reflect daily on how I have learned much from these heroes, who are obviously in the phase of saying goodbye to this life. I have a strong interest in facing the processes of death and dying and the circumstances related to religious beliefs.

Therefore, I would like to highlight and share some of my experience as an oncologist in palliative care.

On one occasion, a black woman, who was friendly and constantly smiling, approximately 60 well-lived years of age, was hospitalized because of terminal renal failure. The urologist provided information that her cervical cancer, recurrent in the pelvis, showed clinical progression following two failed attempts at palliative chemotherapy. During my initial interactions with the patient, I asked what she knew about her illness. I perceived that she was fully aware of the disease and its irreversibility despite treatment.

Therefore, I found an easier path, because the patient denoted openness to discussion of her disease. My thoughts were of an important discussion that demanded attention at that moment, talking about life and death. However, regarding this subject, Mrs. T, whose religion was evangelical, was not open to this discussion, upon perceiving that she would have to accept her mortal condition, as death became ever closer, because she believed a miracle would occur, freeing her from this penitence (death) and from then on it was not possible to discuss the matter.

Mrs T: “Doctor, I really believe in divine providence; in healing by God. In the event of a miracle. He will save me.”

Dr. P: “It is very important that you cultivate your faith and hope; however, we must work with the reality of the facts and scientific evidence.”

Mrs T: “I don't want to talk about such things.”

As we have the support of an interdisciplinary team, I asked for more active presence from the psychologist and music therapist, as well as spiritual help from the chaplain. Mrs. T lived 2 weeks of lucidity, with reasonable control of her symptoms, until she developed progressive dyspnea caused by pulmonary congestion. Her suffering was alleviated with continuous intravenous morphine infusion. It was not possible to perform palliative sedation, because the patient and her sister refused this type of procedure. They believed that sedation could hinder the occurrence of a miracle.

Through my reflection on this experience, I understood that for Mrs. T to accept the idea of finitude and begin not to believe in a miracle would be as if she were faltering, losing faith in God.

From the medical point of view, during the last 2 weeks of the patient's life, my visits and interactions were frustrating, because I limited myself only to approaches concerning physical symptoms and superficial matters. However, I reflect that we tend to indoctrinate others; tend to make them see a situation from our paradigm. My God is less aggressive; He forgives all, but does not perform miracles. In my opinion, miracles are secondary to the work and progress of a person. What we call miracles today will somehow, some day, be explained by the advance of science.

I have never explained this stance, my spiritual position, to a patient. However, subjectively and unconsciously, it is always present in my medical consultations and hospital visits. Therefore, one way that I have found to deal with patients who believe in the occurrence of miracles is to try not to express an opinion on their possible occurrence. I like to say:

Another strategy I use is to draw attention to the small day to day “miracles,” such as not being in pain, not having uncomfortable symptoms, and having inner peace, among others.

Recently, a 33-year-old woman (Ms. D), who had been under treatment in our hospital for 7 years was hospitalized because of a well-differentiated neuroendocrine carcinoma with multiple liver metastases and carcinoid syndrome. She had already been exposed to α-interferon, octreotide, and treatment with metaiodobenzylguanidine (mIBG). She presented with severe heart failure secondary to valvular heart disease caused by carcinoid syndrome, as well as peripheral edema, ascites, and confusion. She had probably evolved with hepatic encephalopathy, although we could not rule out brain metastases, or even a vitamin deficiency, such as pellagra. It was necessary to talk with family members to establish the current situation and determine the prognosis and future treatment strategies. Early on in the conversation with Ms. D's father, a middle-aged man showing anxiety, some difficulty occurred in clarifying Ms. D's advanced and irreversible situation.

Ms. D's father: “Doctor, you understand the medicine of men, but I'm a pastor, a Bible scholar and I understand the laws of God. I believe my daughter is improving and will be healed by God.”

Dr. P: “I agree that your faith is very important under the circumstances. However, from the moment we recognize the incurability of your daughter's disease and the lack of effective therapeutic strategies, we will be in a better condition to work together, identifying D's real needs and providing her the well-being that she deserves.”

Immediately, in a firm voice, Ms. D's father recited a quote from the Bible (John 11:4):

“This illness is not meant to end in death. It is for God's glory, so that the Son of God may be glorified through it.”

Believing in a God who performs miracles can make people more confident and hopeful when they face great difficulties. I believe we should have sufficient sensitivity to identify those who use faith, such as the occurrence of a miracle, as a way of denying or minimizing painful situations. In this context, the assistance of trained professionals, such as psychologists, can be crucial to help the patient and family cope better and more amenably in such situations.

I conclude that, in patients with advanced cancer under palliative care, faith in the occurrence of a miracle is often a difficult point for the health professional in the process of restructuring life and preparing for the death and dying process. The expectations of patients and families often turn to the idea of miraculous healing, the unexpected, not permitting the patient/family to identify other issues beyond the unshakable faith in miracles. Therefore, in these difficult situations, I keep in mind to never enter into religious disputes or convince the patient/family to not believe in miracles. I begin from the viewpoint and professional conduct of identifying cases of denial or escape and of offering the support of the interdisciplinary team. I would also highlight the possibility that grief is less painful for those family members who never stop believing in miracles. I can see that they maintain a clear conscience, because they have never abandoned the belief in the power of a miraculous God, even though they perceive that the life of their loved one hangs by a thread.