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One Problem With End-Of-Life Talks: When They Never Happen

Even the most brilliant (and nicest) docs might be frightened to discuss death.

I read the article in The New York Times, "Facing End-of-Life Talks, Doctors Choose to Wait" (Jan 12, 2010) with interest, but ended up feeling something important was missing.

The piece, which came out earlier this year, cites a study published online in the journal Cancer. The Times reported that "many doctors, especially older ones and specialists, say they would postpone those conversations [meaning the end-of-life ones], according to the findings of the study."

I was a home health social worker for a long time. My experience working with dying patients, visiting hundreds of elderly people diagnosed by their physicians with end-stage diseases who had only weeks to live, taught me that even—or especially—the most brilliant (and often the nicest) doctors might be as frightened of discussing death as their patients are. That doctors are human like the rest of us, and, like the rest of us, are at times timid, ill-equipped and scared, perhaps, to talk about death in a personal way. Saying doctors "choose" to wait makes it sound like their choice is always altogether rational, planned and born out of ethics.

As a clinician, there was nothing more painful for me than to receive a doctor's order to speak to a patient about hospice only to find out the doctor hadn't told the patient and family why. Or being dispatched to a patient's home (or hospital room) only to have the patient's family—or the patient-tell me in tears that they couldn't get the doctor to tell them anything. I'm not saying it's always the doctor's fault. Sometimes patients and families hear, but don't or won't hear. They opt for treatment even when treatment won't work anymore. We all have our blind spots.

But regarding the study, I fear that many people fail to realize that going on hospice is actually a choice that the patient gets to make for himself or herself—or it should be. But it's almost impossible to make such a choice when the treating physician who guides the care plan avoids the subject. The public has the idea that most people receive hospice care for months. Some do.

When I was new to the field more seasoned social workers and nurses told me that doctors only like to focus on solutions, that this explained why they never discussed "What if" with their elderly patients, even the seriously ill. What if, as in, What if the treatment doesn't work? "That's your job," my colleagues told me, relieved someone new was coming in to relieve them of doing just that.

Of course, it is a social worker's job to help the patient process end-of-life issues. And there are palliative care specialists (more in future posts) who, according to a different Times article, " how to deliver bad news, and they do it again and again." And that's good. Because it is the doctor who creates the care plan, who sets the tone of treatment, who leads the care team to best serve the patient. It is the doctor who writes the clinical orders therefore it should be the doctor who also understands that waiting too long to discuss death can cause more torment at the end of life, than peace.

Image credit: Dr Dapper/flickr

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