There is an old joke that illustrates many people's perceptions of the difficulty physicians have discussing prognosis with their patients. According to this story, a nervous patient comes to his doctor's office for follow-up results following a biopsy of a suspicious shadow in his lung. The doctor enters the room with a furrowed brow. The anxious patient blurts out: "Is it bad news doctor? Am I dying?"
The doctor nods: "I'm sorry, I wish it had been better news. But it looks like the shadow is a tumor."
"A tumor? Oh no?"
"It's always hard to put a number on these things," said the doctor. "But I'd have to say, ten..."
"Ten?," the patient interrupts. "Ten what? Years? Months? Weeks?..."
Ok, so doctors aren't normally that bad at delivering bad news. But in a recent post, I laid out a question to readers — about whether and how physicians should discuss the prognosis among patients whose shortened life expectancy is the result of their already long lives. I asked whether doctors need to talk to 85 and 90-year-olds about the fact that they probably aren't going to live a whole lot longer. Dr. Alexander Smith and colleagues wrote a nice essay on this topic in the New England Journal of Medicine in December of 2011. (Google "Discussing overall prognosis for the very elderly" and you will find it.) They report some important facts about life expectancy in elderly patients. For instance, the average life expectancy of an 85-year-old is 6 years. In fact, 25% of 85-year-olds will live at least another ten years. And the majority of such patients (65% according to their own research) want to discuss life expectancy with their doctors.
But what about those other patients, the 35% who don't want to discuss such matters? How do doctors figure out which patients to discuss this uncomfortable topic with and which ones to avoid the topic?
This challenge illustrates how the morality of a situation is inextricably linked with empathy. The right thing to do here is not a matter of Kantian rights or philosophical theories. It is a function of social intelligence. It's a matter of physicians figuring out how to figure out whom to talk this over with, and figuring out how to deliver such news in a sensitive manner.
"If I knew you probably only had, say, six years to live, would you want me to tell you?"
That's probably not the best way to bring up the topic to an anxious patient who is going to fixate on that number.
So what's the best way to discuss such a topic? In short, no one really knows. Researchers have studied how doctors break bad news to their patients and have even found out ways of breaking bad news that work better and worse. They've even developed interventions that improve the way doctors discuss these topics. But they haven't explored the issue of age and prognosis in any systematic way.
Too bad such topics never get covered in medical school!