Doctors often shade truth from
dying cancer patients
CHICAGO -- June 19,
2001 (Cancer Digest) -- "How long have I got, Doc?"
is a fundamental question that terminally ill patients frequently
ask. A study of terminally ill cancer patients and their physicians,
however, found that doctors give the patient his or her best
estimate of how long patients could expect to live in only 37
percent of cases.
Without such knowledge,
patients cannot make informed choices about how to spend their
remaining time or prepare themselves or their families for the
kind of death they would have chosen, given the opportunity.
The study, conducted
by two physicians at the University of Chicago Medical Center
and published in June 19 issue of the Annals of Internal Medicine,
found that in 40 percent of cases, doctors would knowingly provide
an inaccurate estimate of survival time, usually an overestimate.
In 23 percent of cases doctors would refuse to provide an estimate.
"Although nearly
everyone agrees that frank, open and honest communication between
a patient and his doctor is optimal, on this one absolutely crucial
issue it remains very much the exception," said study co-author
Dr. Nicholas Christakis in a statement.
"As a consequence,
two out of three patients may have to make important medical
and personal decisions based on missing or unreliable information,"
said Christakis, professor of medicine and sociology at the University
of Chicago.
The authors worry that
without reliable information patients with no chance for recovery
may delay gathering their families and friends until it is too
late, or chose to undergo costly and invasive but predictably
ineffective therapies. Recent studies, for example, confirm that
many terminally ill cancer patients with unresponsive disease
nevertheless receive chemotherapy.
The investigators conducted
a four-minute telephone survey with 258 Chicago-area physicians
who referred 326 patients to hospice care in 1996. They asked
each referring physician for his or her best estimate of how
long that patient was likely to live. They also asked what he
would say if the patient insisted he provide an estimate of probable
survival time.
In 23 percent of the
cases, physicians said they would not give the patient a precise
prognosis, even if asked. In only 37 percent of cases would the
doctor communicate his best guess at probable survival. In 40
percent of the cases, physicians said they would intentionally
provide an inaccurate estimate, usually suggesting that the patient
would live much longer than the doctor really expected.
"Physicians want
to give patients hope," said cancer specialist Dr. Elizabeth
Lamont, an instructor of medicine at the University of Chicago
and co-author of the study.
"They may imagine
they are being kind or encouraging or even protective by withholding
bad news, but we think that many patients need information about
their survival and that when they ask they deserve a frank response,"
she says.
This tendency to exaggerate
survival time is particularly troubling, note the authors, in
light of previous studies showing that even experienced doctors
making their best guesses tend to overestimate survival times
by a wide margin. Adding an intentional error only compounds
this inherent prognostic bias.
This survey, which
focused only on cancer patients who had already been referred
to hospice for palliative care -- a turn of events with obvious
prognostic implications -- may underestimate the extent of error
and misrepresentation.
"If physicians
infrequently provide frank disclosure to hospice patients with
cancer who request it," note the authors, "they may
be even less likely to provide it to non-hospice patients, with
or without cancer."
Three factors that
correlated with frank communication were the age of the patient,
the doctor's confidence in his ability to make predictions, and
the age of the physician. Doctors were more willing to be frank
about death with older patients. They were more willing to share
their predictions if they felt certain of their own prognostic
skills. Older physicians, however, were less willing to offer
patients a prognosis.
It may be that the
"wisdom born of experience might discourage physicians from
frank disclosure," suggest the authors. More likely, however,
is the fact that older physicians, who trained during in 1950s
and 60s, were taught to "protect" patients from disheartening
news.
"Forty years ago
many physicians would not even tell patients they had cancer,
much less predict the outcome," said Lamont.
"When physicians
can't or won't make predictions about a patient's future,"
said Christakis, "patients may die deaths they deplore in
locations they despise."
If physicians are to
enhance the care of the dying, he added, "they need to start
viewing the death of patients as normal and unavoidable and not
as a personal or professional failure, to be avoided not only
clinically but also rhetorically."
"Communicating
bad news can be an unpleasant and painful process for physicians,"
said Lamont, "But that doesn't make it any less necessary.
Physicians should be trained to do it tactfully and respectfully.They
should face the difficulties involved when seriously ill patients
request accurate information, no matter how hard this information
may be to acquire or communicate."
The researchers conclude
that, at some point, patients might benefit more from having
their doctors shift the focus from providing hope for recovery
to hope for a good death."
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