Dec 3, 2009

What Are My Chances, Doc?

As you may recall from the last post, if Doctor D suspects you might be facing a lethal illness he'll let you know straight up. He brings it up gently, pointing out that any doctor's guess has a lot of uncertainty.

You do, of course, have the right to ask, "How certain are you, doc?"

But here's the secret: MDs hate answering this because we often don't know how certain we are. I'm usually pretty good at predicting what will kill a patient. How good? Results may vary...

In a few diseases there is solid data: 80% of people diagnosed with pancreatic cancer will be dead one year later. Usually, however, the situation is too complex and there isn't any research data to answer the question. Then Doctor D whips out a gut guess.

I once had patient with curable but advanced colon cancer develop urosepsis and then have a heart attack from the septic shock. His family wanted a percentage for his chances. I made one up, "Maybe a 40% chance of surviving the next 24 hours." He survived and went home.

As I said, I'm not perfect.

Percentage numbers don't really mean that much when I'm guessing, but people just like something that sounds mathematical rather than “almost certainly dying” “could die” or “maybe dying but probably not.”

Predicting death is a risky business. Doctor D once had to dodge a fist when D told a dude his dad probably wouldn't make it. (Fortunately crying people can't pull off a good sucker punch!) Doctors also don't like mentioning death because most people don't like to discuss about their own mortality. We vaguely acknowledge we all die sometime, but you don't expect "sometime" anytime soon. Then Doctor D sits you down and says, “Now might be your time.” It's never an easy talk, and it's almost always based on an educated guess.

Doctor D still thinks it is worth letting you know, even if his estimations aren't perfect. Most patients want to prepare themselves and their families if death is a real possibility. I only withhold such information if a patient told me ahead of time they don't want hear any discussion of death.
What do you think? Do you want your doctor to tell you your chances? Even if it is only an educated guess?

Some old MDs never mention the word “death” because “they don't want to take away hope.” Obviously, Doctor D takes the opposite approach. Which would you prefer? For yourself? For your family?


WarmSocks said...

I think I'd want to know and weigh my options. If there's a good chance of recovery, then treatment makes sense, but there's not much point in spending tons of money on treatment that will only postpone death by a few months. I'm looking forward to heaven, so the thought of dying doesn't really bother me. I'd just prefer to see my kids grow up first.

Anonymous said...

On a related but admittedly different note, I wonder if the presence of an advanced directive in the patient's medical record makes any difference to you as a doctor in deciding how to break the news. If there's an advanced directive, for example, it suggests that the patient has at least put some thought into that possibility, I suppose, but I recognize that it doesn't necessarily mean that the patient has a directive because they thought they might need it anytime soon. I guess along those lines, I'm curious as to what percentage (guesstimate) of your patients have an advanced directive in their files or accessible when they need it?

Any thoughts?
What do you think?

Anonymous said...

As hard as it would be, I'd want to know if I was going to die in the near future. I'd definitely appreciate the time to make my own peace with the concept AND to help my family do the same, if I could. I'd have time to let them know my wishes as to end-of-life care in case I couldn't express them when the time came. (and also make a legal document spelling that out. I know what it is, just can't think of the NAME just now. Sigh).

And I'd be just fine with the doctor giving me his educated guess as to how long I have. In fact, I'm sure I'd ask.

Thanks for posting about this, Dr. D. It's a tough, sad, often wrenching subject -- and situation -- for everyone involved, but one we all, without exception, have to face one way or the other in the end.

Doctor D said...

Thanks to everyone for bringing up the issue of living wills. I think that discussing your approach to death when you aren't looking it in the face is really useful.

I wish I could say that all my patients at Crayzee Clinic had a living will, but honestly I spent most of the time I was there trying to drag them into the 21st century on so many other things I never got around to living wills with most patients.

Now, working in an ER I have a lot of discussions about end-of-life wishes. A living will is a useful guide, however, I always give the person the opportunity to review their wishes. People sometimes find what they thought they had wanted in the past changes when they are actually in the situation. It is important to listen to what patients are actually saying now. But the living will is an excellent guide and intro to discussing wishes.

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