I prefer not to think about death, and I suspect most other people are the same way. Sometimes it is thrust upon us, however, such as when a family member is ill or when a disaster strikes, like a major earthquake or the recent Asiana Airlines crash and Lac-Megantic train derailment. The Quebec Legislature’s introduction of Bill 52, a proposal to legalize physician-assisted suicide, may also have led to increased public awareness and thought regarding end-of-life issues. Current Oncology published a series discussing the right to die and the policy and ethical issues surrounding it.
Whether prompted by the above or not, recently published articles have asked why doctors “don’t do death.” Another series examined “unwanted” end-of-life care – measures aimed to delay the inevitable, but which can result in increased suffering or discomfort for no significant benefit.
These are worthy issues for all to consider, not least those who work with, or care for, cancer patients. Though most of us, myself included, are not palliative care physicians, we certainly work closely with them and are often tasked to manage symptoms, emotions, and needs of patients with incurable, though not necessarily untreatable, conditions.
Do doctors “do” death? As a new physician (and one still in training), I have received training in managing common symptoms patients encounter (pain, nausea, etc.) associated with incurable or progressive disease, oftentimes through direct teaching and experience with Palliative Care physicians, whose careers and academic interests focus primarily on determining how best to do that. And I have seen efforts to educate other physicians, whether in medical school, residency training or in practice, on these same issues. Perhaps the messages are not disseminated as widely, or internalized as readily, as we’d hope, but the efforts are there and getting better all the time. While the linked articles describe doctors not wanting to confront a patient’s death for a variety of reasons, efforts to encourage physicians to do just that are intensifying and are increasingly successful.
But perhaps this is not entirely the correct question. Is death meant to be “done” by doctors? Certainly those of us working in oncology regularly meet with people who are, unfortunately, destined to die of their cancer. We have experience and expertise in treating these patients, to enhance both quality and quantity of life.
Is death, ultimately a medical issue? Few can argue that treating symptoms in advance of death and negating suffering can be aided by medical expertise. Discussions about likely outcomes or futility of care, or how to manage end-of-life pain are well within the physician’s realm.
But end-of-life care, and planning for end-of-life issues, is about so much more than this. It requires advance thought, even when those thoughts might be difficult for patients, family members, medical staff, and others. It requires an understanding not only of the patient’s disease (what treatment options are available, realistic discussions of outcomes and side effects, the costs and benefits of foregoing treatment) but also the patient’s wishes, goals, and hopes. Does the patient want to “try everything” or would they accept perhaps a shorter quantity of life but in familiar surroundings with family and friends? There is no one correct answer, but determining a specific patient’s correct answer requires careful thought and time.
For all the talk about doctors not “doing” death, or not doing it properly, I think we are on the right track. Our ability to treat the more “medical,” or symptomatic, aspects of end-of-life care is good and ever-improving. Our next step should be to encourage patients to consider their end-of-life wishes at appropriate times, even when this might seem difficult or scary. But physicians cannot do this alone – input from patients, their families, and other health care workers is required to ensure that patients understand these issues and know what to do when the time comes to act on them.