Dr. Roach: A doctor’s prognosis can be sentence or gift
Dear Dr. Roach: My understanding is that physicians are taught: “First, do no harm.”
In my opinion, they often do by telling terminally ill patients how long they have to live. This happened in the case of my brother, who was given six months. From the day of that pronouncement, every moment we spent together was overshadowed by this knowledge and the unbearable pain it caused.
The rationale: People need time “to get their affairs together.” In my experience, people have few affairs to attend to; those who do usually have things in order.
The problem is that doctors cheat us of the joy of our remaining life by making us watch ourselves die. What could be more cruel than that?
Dear E.O.: I think it is hard for you or me to decide what is right for all people in all circumstances.
The oath of Hippocrates does, indeed, say to do good, or at least to do no harm. It reminds us as physicians to consider that our actions have the possibility of causing harm and that we must always weigh the expected benefits against those possible harms.
In the case of giving a prognosis about mortality, it is important to remember that physicians are poor at guessing when our patients will die. An experienced and honest physician will admit that our guesses can be wildly wrong, and usually we err by guessing that our patients have more time than they do.
The most important point, however, is that different people have different feelings about how much they want to hear. Also, what people say may not always be what they mean, since some people feel they need to say that they want to know, even if they don’t. I will respectfully disagree that doctors make these statements callously or without thinking of the consequences. Having this discussion with someone, perhaps a patient you have known for years, is not done lightly or without thinking.
Having had this conversation many times (more than I’d like) in my career, I can tell you that my approach is to ask how much the patient and family want to know about prognosis and try to listen not only to words, but to body language. I try to find out what they think their prognosis is. Occasionally a patient will tell me that they want only their family to know and not themselves, and others don’t want to know at all and just wish to hear the options for treatment. I feel we are obliged to respect the patient’s wishes. Only if they want to know will I give my prognosis, admitting possible error; for example, I might say, “I think you have a few months left, but it might be only a few weeks, or it could be a year or more.” It has been my experience that most people want to know, and that most are relieved to have some information, however imperfect. For those, having some idea, perhaps, lets them make more-informed choices about how to spend their remaining time meaningfully.
Email questions to ToYourGoodHealth@med.cornell.edu.