How Not to Talk to Someone Dying of Cancer

Screen Shot 2014-10-12 at 6.49.00 PMA friend of mine has been living well with lung cancer for five years — working, running several miles a day, traveling, doing good stuff with his family, and generally enjoying the pleasures of everyday life. He knows the cancer will eventually kill him, but has been making the most of every remaining minute.

Then, a month ago, things suddenly turned dramatically south. Severe shortness of breath, constant coughing, sleeplessness, fatigue, loss of interest, anxiety. My friend figured the jig was finally up — that he was going terminal. We all felt sad in the face of this inevitability. In our different ways, we began the painful process of saying goodbye.

Then things seemed to get even worse. I accompanied my friend to visit his lung doctor — an amiable and thorough man who spent lots of time with us, took a good history, and did many tests.

We gazed expectantly as the doctor came back into the consulting room and began gravely summarizing his findings. He brought what seemed to be terrible news: “I am really worried about you. Your oxygen saturation has dropped below 90 and your breathing is suddenly getting much worse. This kind of sudden deterioration can be caused by one of four things — pneumonitis from your previous radiation treatment, pulmonary embolism, pericarditis, or infection.”

My friend had been as low as I could imagine before the visit. But now his face went white, his mouth sagged, he began to tear, and the shortness of breath and cough became more palpable. Death seemed about to suffocate him.

“Wait a minute, Doc” I said. “I don’t understand. How about the cancer? Are you saying the cough and reduced oxygen are not caused by the cancer.”

“Right. I checked all the scans and the cancer hasn’t changed at all. It can’t be causing this.”

“And how treatable are these four new possible causes?”

“Very. We have to do some more tests to figure out which it is. Probably pneumonitis and that’s easy to treat with low dose prednisone. The other things are also very treatable. My guess is that the cough and shortness of breath should be OK in a week or two.”

With a new lease on life, my friend returned quickly from death’s door. The transformation was immediate and unmistakable — I have never seen a human being change demeanor so fast. Face filled with joy, he thanked the doctor for inspiring such confidence. There was a renewed bounce to his step as we left the office that I had never expected to see again.

And even more remarkable, my friend’s cough and shortness of breath began improving almost at once. There is a strange healing power in a doctor’s words that has allowed doctors to be useful over the millennia even when their treatments were ineffective or harmful. Reduced fear and renewed hope are wonderful medicines.

The doctor had certainly done a lot of things very right — spending substantial time with his patient, doing a careful evaluation, and that final guarantee of success.

But the doctor had done one thing that was incredibly stupid. He should have entered the room with a bright smile and said something like: “Congratulations. Great news: it’s not your cancer causing these new problems. There are four different possible explanations. With a few more tests, we can figure out which one is responsible and you should be feeling much better within a couple of weeks.”

How could a smart and caring doctor say such a dumb thing to so vulnerable a patient? Simple. We overtrain our doctors on the overvalued technical aspects of medicine and under-train them in the undervalued relational skills that have always been at the heart of healing.

6 replies »

  1. Physicians can to a better job communicating, of that there is no doubt. The movement to make physicians less paternalistic and more ‘non judgmental’ has created some robotic fact-churning doctors.

    Excellent communication is an art which needs considerable judgment about the patient’s affect and the likelihood and treatability of the differential diagnoses.

    Cheery optimism may be out of place as well, or may not be. The four diagnoses quoted above have a high morbidity and mortality particularly in a compromised lung.

  2. Allow me to share a disagreement we used to have in our department.

    Test results came in late in the day on a Friday. Or invariably last thing before a holiday weekend. Bad news. The owner of the test results is not likely not going to be around much longer …

    Yours truly always did the same thing. I made a point of calling. If necessary, I stayed late to make the call.

    Why? It seemed unfair to withhold information from a patient. I was doing my duty. If I got bad news, I would want to know about it, I reasoned.

    Then one day another doctor overheard me dutifully making a call at 5:45 on a Friday afternoon.

    Why’d you do that? Why ruin their weekend?

    I mean, shit. it’s not as if it going to make any difference. I’d never call. Give ’em a gift. Give ’em that last weekend.

    A somewhat heated discussion ensued. At some point during the heated discussion I believe the words “you’re playing God” and “that’s not how I was trained” were thrown around by me. I left work in a bad mood.

    Then I went home and thought about it.

    The next time a test came in on a Friday. I reached for the phone and stopped myself.

    I called to break the news first thing on Monday morning.

    It’s the little things.

  3. Excellent post. The power of language to bring about a positive or negative effect. Very interesting indeed.

  4. It was what the EMR listed to tell the physician to say. Really, you can’t see the course of care disintegrating to this???

    With Obamacare now entrenched and off the list of concerns for voters to focus on next month? Yeah, ISIS and Ebola are going to be affecting us for years to come. Maybe, or maybe not.

    Wait for it, watch how cancer patients are treated by 2016, this above example will be pleasant by comparison.

    I’ll leave you with this old but timeless joke to enlighten and entertain the masses who will spin this thread otherwise:

    “A man complains to his friend “My elbow hurts — I’d better go to the doctor.”

    “Don’t do that,” his friend volunteers. “There’s a new computer at the drug store that can diagnose any problem quicker and cheaper than a doctor. All you have to do is put in a urine sample, deposit $10, and the computer will give you your diagnosis and a plan of treatment.”

    The man figures he has nothing to lose, so he goes down to the drug store. Finding the machine, he pours in the urine and deposits $10. The machine begins to buzz and various lights flashed on and off. After a short pause, a slip of paper pops out which reads:

    You have tennis elbow. Soak your arm in warm water twice a day. Avoid heavy labor. Your elbow will be better in two weeks.

    That evening, after some contemplation, the man begins to suspect fraud and decides to test the machine. He mixes together some tap water, a stool sample from his dog, and urine samples from his wife and teenage daughter. To top it all off, he masturbates into the jar.

    He takes this concoction down to the drug store, pours it into the machine, and deposits $10. The machine goes through the same process, buzzing and flashing before finally printing out the following message:

    Your tap water has lead.
    Get a filter.
    Your dog has worms.
    Give him vitamins.
    Your daughter is on drugs.
    Get her in rehab.
    Your wife is pregnant.
    It’s not your baby — get a lawyer.
    And if you don’t stop jerking off, your tennis elbow will never get better.”

    Read more at http://www.top10-best.com/d/top_10_best_doctor_jokes.html#jEk8IUyqL4QmQYui.99

    Have a nice weekend,
    Joel H