Wednesday, September 22, 2004

The Oncologist as Soothsayer

Is it compassion, or a morbid fascination with death that compels a medical oncologist to volunteer to predict how long his or her patient will live? It is almost a cliche' to say that the oncologist is always asked to provide the number of weeks, months or even years a cancer patient has to live. Since no honest mortal will admit to possessing the gift of prophecy, why do we attempt to answer this question? Any specific length of time given is obviously a lie, yet we oncologists continue to pronounce the forthcoming date of demise with Olympian solemnity, sending the whole room into a stone-faced silence, or we awkwardly yammer on about the statistics of survival: median, one-year, relapse-free, until everyone (the doctor included) is confused.

I realize that end-of-life plans must be made, and courage must be summoned to face the grief ahead, but predictions of survival are not only notoriously inaccurate, but also tend to add needless stress - especially if delivered in a rather cavalier manner (no need to look grim in front of the anxious family) that only induces shock. Predictions are an act of cruelty. They mark the future as a time of painful waiting, as if a calendar date circled in black is hung on the kitchen wall - ripping hope out of the hearts of the patient and loved ones.

Despite this, it is impossible for an oncologist to not comment on the request for predicting the length of time a patient has to live. It is a reasonable query, asked by concerned and loving caregivers. Often when I respond with a number it is because the end of life is very near, and I believe the family is better off forewarned and emotionally prepared, rather than stunned by the sudden announcement.

I personally have found it more helpful to use this occasion as a chance to sow encouragement, and shift the focus of all onto the life of the patient. Treatments are changing constantly, and who can say that a new drug may not lengthen the life of a seriously ill patient in the months or years ahead? I tell patients that if the cancer they have is associated with an average survival of 12 months, that means that half of the group is still alive after a year - why not cheer for the patient to be in that group?

It is a waste of a medical oncologist's career to not use any appropriate opportunity to encourage, to build up, to look for good news to share, to predict that relief of suffering, if not recovery, is just around the corner. It is easy to be the bearer of bad news in this world - but an oncologist should always carry the light of hope inside, and shine it on the cancer patient just when his or her world seems darkest.


At 11:42 AM, Blogger Hospice Guy said...

I assume from this post that you do not bring up time frames unless you are asked. Does this ever weigh in your mind when thinking about making a hospice referral. (This of course assumes that you do refer patients to hospice.)

I have a frustration with the Medicare hospice benefit because it is time related. I find it unfair and somewhat dishonest to hang the hospice benefit on the expected length of the patient's life, since we are, at best, guessing. Just wondered if a doctor shares those feelings.

At 9:56 PM, Blogger Dr. Craig Hildreth said...

To Hospice Guy:

I think the use of an arbitrary length of time to justify a hospice referral is ridiculous, and would not hesitate to enroll a patient in need, even if he or she lived longer than six months.


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