Nov 27, 2009

Recognizing Death

A reader with a bad illness writes:

I would prefer that my doctors give me any bad news straight up. I'm not confident they will. No one is saying anything definitive. I've asked two of them about my prognosis. One said, "I can't tell you that." I don't really think anyone knows, but I wonder if they just don't want to tell me bad news?
Predicting the end of life is very difficult even for the most knowledgeable doctor. People with certain conditions are obviously closer to their death, but estimating how and when a person will die is extraordinarily difficult. With some illnesses (like common cancers) we can say what percentage of people will be dead in a year, but a percentage from a study doesn't tell you with certainty how long one individual will live. And most life-ending situations don't have good percentage studies. Still, experienced doctors become pretty good at recognizing when a person's body is declining and fighting a war that it won't win.

One thing that frustrates Doctor D is that MDs often talk amongst themselves about a person's prognosis without frankly mentioning it to the patient. They discuss the disease process in such techno-medical jargon that you don't recognize they are saying you will probably die. The confusion is intentional. They don't want you to hear the word "die" because they are often afraid to discuss with you it themselves.

Death is hard to discuss. No one likes to give bad news. You are telling a person about the end of their life. It is a heavy conversation. Since all they have to offer are educated guesses, doctors often busy themselves and the patient with the technicalities of treatments and tests—until the end is obvious and undeniable. Only then do we frankly discus dying. By then, death is sometimes so close patients have almost no time to prepare themselves and their families.

Your doctor is technically correct. A doctor cannot tell you exactly how and when you will die. But your doc may have a good guess as to where things are headed.

Give your doctor permission to guess. Let the doc know you won't be angry if they cannot win against the disease. Only then are you likely to get a straightforward estimate.

Doctor D has a policy of not hiding his guesses from patients. If I think a person may have a life-ending illness I won't keep it a secret. I point out that I am not certain, but I need to let them know my suspicions. It is hard to discuss someone's mortality, but I believe it is one of the most important duties of a physician with a patient facing a potentially fatal illness.

Of course the next question everyone asks is "What are my chances?" and "How long do I have?" These are also difficult questions to answer, so I will save them for a later post.
All of us will eventually die, but today you have your life and the lives of those around you to be thankful for. So today forget about shopping and tell someone that you love them. See you next week!


Maha said...

This is the part of your job that I do not envy at all.

Anonymous said...

It sounds hard, yes, but for a doctor who likes to make a real connection with patients, I would think it could be a very special, intimate sort of conversation. What is said and how it is said really matter. How many of us share such a moment with people in our ordinary work days?

Doctor D said...

Like any consideration of death with someone you care about it is intimate in a sad way.

Fortunately it isn't on most work days that I tell someone their death is coming soon. Although, I suppose when I discuss preventive medicine my job is to remind people that their death is coming eventually.

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