Saturday, December 6, 2008

Should The Doctor Say You Are Dying?

Most Oncologists say they would tell a terminally ill patient that they will die. But in the same survey of over 700 Oncologists, published in the Journal of Clinical Oncology, it was revealed that 48% of the doctors would talk about death only when their patients said "yes" they wanted to talk about it. Also, less than half of the oncologists (43%) said they would give an estimate of the time a patient has left to live. Yet 74% of those same doctors said THEY would want to know their prognosis, including a time frame of when death could be expected.

We are a society that is very uncomfortable with death. We offer unrealistic expectations of survival in patients with advanced terminal cancer and patients with end stage cardiac or pulmonary disease. There is always "one more" new drug or hospitalization that can be offered and physicians and families do not want to take away "hope". Doctors are stuck between a rock and a hard place because patients don't want to be"quitters" and they don't want a physician who will give up.

It is far easier to offer another course of Chemo than to have the difficult conversation that says; "This time with your family is important time. Chemo will make you feel weak and sap your strength and you will be on medication that will make it hard to think and communicate and enjoy your life. I would rather help you have as much strength and energy as possible and line you up with Hospice programs that can help with your symptoms and equipment needs so you can be at home. I will continue to be your doctor and we can change our mind at any time if new treatments are available or if it looks like things are improving."

Eighty percent of all deaths occur in a hospital. How would you like to spend your last days?


jobb said...

I would like to know when, so I could say how and where.

Steven Reidbord MD said...

The oncologist survey doesn't alarm me. Talking about something (eg, death) only when your patient wants to is respectful of patient autonomy. Some patients want lots of information to make health-care decisions, others don't. Oncologists should, of course, offer an estimated time course if patients want to know this. Maybe they hesitate because they don't want to deprive patients of hope for a miracle (or just a statistically unlikely but happy outcome). It's a tough balance.

Since we MDs tend to be data- and detail-oriented, it doesn't surprise me that 74% of us want all the details, compared to a smaller percentage of the general public.

I agree that our society is very uncomfortable with death. However, I'm not sure what it means that 80% of us die in hospitals. Many deaths are unanticipated, and being in a hospital is a good way to try to stay alive. For deaths that are anticipated, most of us would prefer to be elsewhere, for example at home surrounded by loved ones.

I think it was Woody Allen who said: "I don't fear death. I just don't want to be there when it happens."

Anonymous said...

I would like to talk to my internist if I was dying as well as or more then the oncologist. I think I could be more comfortable and beneficial talking to my internist and find it valuable because of seeing the warm and human, caring side and the relationship there is combined with the years of knowledge.

I would like to know I was dying and even a time estimate keeping in mind that it is not always accurate but can be depending on the disease, but individuals don't alwasy fit the statistics. I would want to see and talk to the people important to me that I'm close to and maybe do and experiance some things while I still had energy and strength.

I have had to deal alot with terminal illness, hospitals, nursing homes, hospice,morticians and talk about it these last few years with a combination of eight friends and relatives.

I especially like the third paragraph of what to really consider and decide about.

Thank you for bringing this excellent blog on a tough importnat subject up Dr.Brayer.

tracey said...
This comment has been removed by the author.
tracey said...

I know your blog is directed to other doctors, but follow anyway. : ) I had - and was treated for thyroid cancer - one of the non-aggressive forms - so I didn't have an oncologist. I saw my PCP & an Endocrinologist. My cancer was bush league compared to what other types of cancer patients go through for treatment - all I had was surgeries and radiation. However, I am extremely grateful for doctors, including my surgeon (who had an exceptionally good beside manner - especially for a surgeon) that took the time to explain what I could expect depending on the choices in treatment I made. Again, I had thyroid cancer which is nothing compared to other types, but it helped to know what I could expect in terms of life span or recurrance of my cancer. I'd rather know, even if it's a difficult conversation.

Christian Sinclair, MD said...

For a discussion of this study from a palliative care physician's perspective, Dr. Rosielle at Pallimed posted on this article a little bit ago.

I think there could be a mistaken perception that our society as a whole is uncomfortable with death if the topic is dealt with in a professional and compassionate way, especially understanding the uncertainty that some commenters allude to.

Patients don't want to be quitters, but when we always couch treating cancer as a battle, it is difficult to overcome a sense of 'losing' or other pejorative terms when the goals change from curative or maintenance to palliative.

Thanks for bringing some attention to this study.

On a side note, I would recommend linking or citing the journal article more specifically so that when people search for that article they may stumble upon this post. is a great service for coordinating bloggers who are writing to any degree about journal articles.

Toni Brayer MD said...

Dr. Sinclair: Thank you for the tips and I have visited pallimed many times in the past.

Anonymous said...

Another difficult issue here is the unpredictably of individual patients. In the opinion of this med student, the most difficult part of the end-of-life discussion is giving concrete answers. You can only tell people what the stats say. I had a patient who was having everything done because last time, the doctors told him he wouldn't make it. He left and came back, so him and the family didn't believe anything the docs said.

It's really hard to give accurate predictions, which makes it harder to have good discussions.

Christian Sinclair, MD said...

Anon makes a great point in that we have very little data helping physicians make accurate prognostications for individual patients. Making big misses are bound to erode trust as Anon related. But a big error many physicians succumb to is seeing communicating prognosis as a single static event instead of an ongoing discussion as the situations changes. More frequent discussions about what is expected with the explanation about the degree of uncertainty, since some things are more certain than others.

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