Time to Stop Ringing the Bell? A Look at Patients’ Varied Reactions to the End-of-Treatment Tradition

A QUIETER APPROACH

Clinics may want to investigate alternatives such as awarding a certificate at the end of treatment in a quieter, less public ceremony. Senior study investigator Richard Jennelle, MD, associate professor of radiation oncology at USC, said the bell is a complicated experience and although very well intentioned, it clearly impacts patients very differently than had been expected. “So, many things in the practice environment can have unintended consequences,” he explained. 

This is similar to what he has seen with microwave popcorn in the clinic. “Every once in a while someone burns a bag. That is a horrible experience for many of our patients who are already sensitive to smell. Understanding this, many practices have become more cognizant of how the environment impacts patients,” Dr Jannelle explained. “I think the bell is very much like that and may have very negative influences on patients who especially feel excluded.”

Mr Gale, who wrote a letter to the editor on how he was personally affected when his mother was being treated for stage IV colon cancer, explained that at the Straub Cancer Center in Hawaii patients who have completed therapy receive a small gift and a card signed by the treatment team.² At the University of Washington Cancer Consortium, the patient is given a certificate. Mr Gale thinks that the bell ringing ceremony needs to be stopped entirely. “I advocate for immediate change. I used my Mom’s story of sadness as an example of the unintended consequences. Even if only one more patient with a terminal diagnosis has that same sadness, one patient is one too many,” he said.

Christopher R. Friese, PhD, RN, professor of Nursing, Health Management and Policy at the University of Michigan Rogel Cancer Center in Ann Arbor, said patients have many divergent paths during their cancer treatment as some are cured and others require ongoing treatment, and this must be factored in at each institution. “I’ve had patients who were reluctant to ring the bell and others saddened that bell ringing may never happen for them. It’s time to retire the bell-ringing ceremony in oncology practices and replace it with the celebrations that best meet our individual patients’ needs. A better option might be a thank-you card to patients and families for putting their trust into our hands. That way, all patients and families can participate equally,” suggested Dr Friese.

Michelle Bednar, BSN, RN, assistant nurse manager in the Department of Radiation Medicine at Oregon Health & Science University (OHSU) in Portland, said at her institution each patient has the option to choose whether they want to ring the bell, and many have thoroughly enjoyed the experience. “However, it is important for our oncology nurses and care team to help each patient contextualize the bell ringing ceremony. All of our patients are at a different point in their treatment course at the completion of radiation, so this ritual may have a different meaning for each individual,” Ms Bednar explained.

Oncology nurses prepare each patient for what to expect when treatment is over and that is often the period when side effects are at their peak. Currently, OHSU is not dropping its bell-ringing ceremony based on just one single institution study. “As new evidence emerges, we will continue to evaluate the impact of this end-of-treatment celebration. I am curious if the patients surveyed about the bell ringing were also given the same framework for seeing the bell ringing ceremony not as an end to their treatment, but as a milestone along their journey to survivorship,” said Ms Bednar.

References

1. Williams PA, Hu J, Yang D, Cao S, Jennelle RL. The cancer bell: too much of a good thing? Int J Radiat Oncol Biol Phys, 2019;105(2):247-253.

2. Gale KJ. Inappropriate celebration in the presence of patients with poor prognosis — the cancer center victory bell. JAMA Oncol. 2019;5(2):146-147.