DEAR DR. ROACH: My understanding is that physicians are taught: “First, do no harm.”
In my opinion, they often do by telling terminally ill patients how long they have to live. This happened in the case of my brother, who was given six months. From the day of that pronouncement, all we saw was the end moving closer and closer. Every moment we spent together was overshadowed by this knowledge and the unbearable pain it caused us and him.
The rationale: People need time “to get their affairs together.” In my experience, people have few affairs to attend to; those who do usually have things in order. Most of us can handle everything that needs doing in a day or two. Maybe rich doctors must their affairs together,” but this isn’t a problem for most of the rest of us.
The problem is that doctors cheat us of the joy of our remaining life by making us watch ourselves die. What could be more cruel than that? The last birthday. The last Christmas. The last football game! We endured it all, and we suffered through every minute of it. All hope had been ripped away!
I wish doctors really understood the pain and harm of such callous statements. If you balance the positive against the negative, it’s clear that this is an inhumane practice. — E.O.
ANSWER: I appreciate your asking this question, but I think it is hard for you or me to decide what is right for all people in all circumstances.
The oath of Hippocrates does indeed say to do good, or at least to do no harm. It reminds us as physicians to consider that our actions have the possibility of causing harm and that we must always weigh the expected benefits against those possible harms.
In the case of giving a prognosis about mortality, it is important to remember that physicians are poor at guessing when our patients will die. An experienced and honest physician will admit that our guesses can be wildly wrong, and usually we err by guessing that our patients have more time than they do.
The most important point, however, is that different people have different feelings about how much they want to hear. Also, what people say may not always be what they mean, since some people feel they need to say that they want to know, even if they don’t. I will respectfully disagree that doctors make these statements callously or without thinking of the consequences. Having this discussion with someone, perhaps a patient you have known for years, is not done lightly or without thinking.
Having had this conversation many times (more than I’d like) in my career, I can tell you that my approach is to ask how much the patient and family want to know about prognosis and try to listen not only to words, but to body language. I try to find out what they think their prognosis is. Occasionally a patient will tell me that they want only their family to know and not themselves, and others don’t want to know at all and just wish to hear the options for treatment. I feel we are obliged to respect the patient’s wishes. Only if they want to know will I give my prognosis, admitting possible error; for example, I might say, “I think you have a few months left, but it might be only a few weeks, or it could be a year or more.” It has been my experience that most people want to know, and that most are relieved to have some information, however imperfect. For those, having some idea perhaps lets them make more-informed choices about how to spend their remaining time meaningfully.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or request an order form of available health newsletters at P.O. Box 536475, Orlando, FL 32853-6475. Health newsletters may be ordered from www.rbmamall.com.
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