“If you have cancer, maybe you don’t want to talk with your oncologist about death and dying because you want them to save your life. So you don’t even want to go there. And then you’re admitted to the hospital you’re told, ‘You’re extremely sick; you have pneumonia, but if we intubate you, we might be able to turn this situation around versus, if we don’t intubate you, you will surely die.’ And people don’t want to make that decision, because they’re not ready to die, even if ideally they’d want to have that good death,” says Dr. Chittenden, noting that not all providers have come to terms with how to use the available medical technology, when to stop using it, and how to talk about prognosis.
Talking about Prognosis
“In no case of serious illness … is predicting the future straightforward or meaningless,” writes Nicholas Christakis, in Death Foretold: Prophecy and Prognosis in Medical Care.16 “Part of the problem is that even formulating, much less communicating, a prediction about death is unpleasant, so physicians are inclined to refrain from it. But when they are able to formulate a prediction and fail to do so, the quality of care that patients receive may suffer.”
According to Dr. Epstein, you have to practice the conversations. “It’s a skill set, just like doing a bedside procedure … something that you have to do over and over and get comfortable doing,” he explains. “And it shocks people out of their seats when they actually hear the ‘D word.’ ” But part of meeting your responsibility to patients and their families requires speaking the truth.
Dr. Epstein says there are numerous resources available to help hospitalists overcome their discomfort and fears about being incorrect about how long the patient has to live. “I think it is OK to also say, ‘Look, I’m not God and I don’t have a crystal ball, but I have seen lots of people in your situation and having watched them go through this point in their life, this is my expert opinion … ,’ ” he advises.
This involves telling the patient, “These are your chances of making a full recovery to the point where you might appreciate the quality of life you would have.” You don’t have to give numbers; you can use words such as good, bad, or poor.
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For those with advanced systemic failure, you might discuss prognoses in words that patients can better understand by making a comparison to someone has a cancer diagnosis. For instance, “I’ll say, ‘Your chances for living for a year are about as good as someone living with metastatic lung cancer,’ ” says Dr. Epstein. “I think that’s something that patients grasp a lot easier.”
In addition to the fear of being incorrect in prognosticating, physicians often don’t want their patients to lose hope. “Whereas in truth people are already thinking about these things, and there are studies that show people want their doctors to bring it up,” says Dr. Chittenden.7
A number of these studies were conducted by Dr. Christakis and Elizabeth Lamont, MD, a medical oncologist now practicing at Massachusetts General Hospital Cancer Center and assistant professor of medicine and health care policy at Harvard Medical School.15,17-19 Their findings have shown that doctors’ inaccuracies in their prognoses for terminally ill patients are systematically optimistic and that this may adversely affect the quality of care given to patients near the end of life.17