I guess I'm in the minority since I don't care why my patients die. I don't care about the diagnosis, co-morbidities, etc. Everyone dies of the same thing - their heart stops beating and they stop breathing. What I focus on is them, inside and out. Where have they come (farm land, substandard living conditions, ...), who are they (strong, commanding, shy, meek, outlook on life and death...), what's happening (skin color, appetite, current priorities, eyes, smell,...), and finally outside influences (family judgements, friends with unfounded advice, recluse, do they put weight on what Dr. Oz says to be true, .....). And when my patients ask me for my opinion as to their condition and prognosis I tell them the truth as I know it to be and sometimes that means I say I'm not sure.
I have finally looked at myself as a visitor to this life. I get to stay awhile and move on. I’ve been predicted to die so many times over my life with complications secondary to myelomeningocele that I used to think I’m going to need to KNOW when my time’s up - I’m a fighter and a survivor...but I don’t want that to get in the way of leaving when my time’s up. I can embrace the old phrase “Today is a good day to die” because I will continue to die living rather than live dying. Great essay, Dr. Cifu!
As a nurse, I have experienced that patients do often know...I also hate the feeling of knowing there is something wrong in your body but no one can find an answer to it.
‘Can I tell you my fear?’ is such a powerful invitation towards shared decision making in patient care. Hard to be candid when it’s just a feeling or gut instinct though. Great read!
Kind of what I was getting to in that case, where patients "refuse" to accept what is obvious. I do think it is usually just an approach to dealing with the reality.
What I meant to say was situations where the doctor is certain the patient is going to die in a short period of time and then the patient goes on to live for a prolonged period of time
Brilliant discussion. Medical students should be exposed to this kind of analysis, wisdom, and learning by reflection exemplified in this piece. Nurses learn about the breadth of health beliefs but, as far as I know, medical students never are. If they are good listeners and have common sense, they learn over time.
Adam, you may be right but we should try to teach nurses. APPs and med students. The psychology, health beliefs and cultural "baggage" of our patients are vital factors influencing the way our patients understand, accept, and implement our recommendations. It is not just how articulate and understanding the caregivers might be. When I was a medical student, I read a profound book entitled, The Patient as Person, by Paul Ramsey. Really deep and spot on. In addition, Norman Cousins' book, The Anatomy of an Illness, is a profoundly personal and insightful story about the importance of the physician-patient alliance and the reality of the placebo effect. I recommend both to you and our readers.
When my best friend of fifty years (she was also my first cousin and we had grown up together in the same NYC building) was very sick with advanced ovarian cancer we called a local doctor who did both hospice and palliative care work to come over for a home visit. She visited with my cousin for about a half hour and then spoke privately with us in the kitchen. I asked her what her opinion was of the current timeline between life and death. She responded: we always ask ourselves if we would be surprised if our patient died tomorrow and I would not be surprised. I think she may have a few more weeks.
She was honest and told us her opinion about my cousin's situation.
And that was what happened.
My beloved friend died a few weeks later as we held her hands in her bedroom.
The combination of being an EBM/obsessed diagnostician (Dr. House?) and landing on quadrant B without evidence must be quite disconcerting! As a student of human behavior, I think it's fascinating the myriad ways people cope with existential matters, and those who work with the dying say that we tend to face death in the same manner we face life, or as somebody put it, "The way we do one thing is the way we do everything." I'm working on the way I do everything, in the hopes that by the time I face death, I've finally got it right!
Thanks. Insightful. I hope to know and for my doctor to know. Healthy at 80, I feel I have had my share of life and am thankful for it; I hope to have more and not painfully more.
I guess I'm in the minority since I don't care why my patients die. I don't care about the diagnosis, co-morbidities, etc. Everyone dies of the same thing - their heart stops beating and they stop breathing. What I focus on is them, inside and out. Where have they come (farm land, substandard living conditions, ...), who are they (strong, commanding, shy, meek, outlook on life and death...), what's happening (skin color, appetite, current priorities, eyes, smell,...), and finally outside influences (family judgements, friends with unfounded advice, recluse, do they put weight on what Dr. Oz says to be true, .....). And when my patients ask me for my opinion as to their condition and prognosis I tell them the truth as I know it to be and sometimes that means I say I'm not sure.
I have finally looked at myself as a visitor to this life. I get to stay awhile and move on. I’ve been predicted to die so many times over my life with complications secondary to myelomeningocele that I used to think I’m going to need to KNOW when my time’s up - I’m a fighter and a survivor...but I don’t want that to get in the way of leaving when my time’s up. I can embrace the old phrase “Today is a good day to die” because I will continue to die living rather than live dying. Great essay, Dr. Cifu!
As a nurse, I have experienced that patients do often know...I also hate the feeling of knowing there is something wrong in your body but no one can find an answer to it.
‘Can I tell you my fear?’ is such a powerful invitation towards shared decision making in patient care. Hard to be candid when it’s just a feeling or gut instinct though. Great read!
D is quite a bit more common these days, Adam. Sudden unpredicted death in people in the prime of life is up 40% since 2021.
How about the inverse of this: situations where you know the patient is going to die with certainty and they do not?
Kind of what I was getting to in that case, where patients "refuse" to accept what is obvious. I do think it is usually just an approach to dealing with the reality.
I did not make myself clear.
What I meant to say was situations where the doctor is certain the patient is going to die in a short period of time and then the patient goes on to live for a prolonged period of time
A couple of patients who warned me they would die during low risk surgery come to mind...I dismissed their concerns as mere nervousness...
Did they die?
yes
Brilliant discussion. Medical students should be exposed to this kind of analysis, wisdom, and learning by reflection exemplified in this piece. Nurses learn about the breadth of health beliefs but, as far as I know, medical students never are. If they are good listeners and have common sense, they learn over time.
I wonder if it is the kind of wisdom that doctors and nurse get from caring for people but, maybe, cannot be taught?
Adam, you may be right but we should try to teach nurses. APPs and med students. The psychology, health beliefs and cultural "baggage" of our patients are vital factors influencing the way our patients understand, accept, and implement our recommendations. It is not just how articulate and understanding the caregivers might be. When I was a medical student, I read a profound book entitled, The Patient as Person, by Paul Ramsey. Really deep and spot on. In addition, Norman Cousins' book, The Anatomy of an Illness, is a profoundly personal and insightful story about the importance of the physician-patient alliance and the reality of the placebo effect. I recommend both to you and our readers.
When my best friend of fifty years (she was also my first cousin and we had grown up together in the same NYC building) was very sick with advanced ovarian cancer we called a local doctor who did both hospice and palliative care work to come over for a home visit. She visited with my cousin for about a half hour and then spoke privately with us in the kitchen. I asked her what her opinion was of the current timeline between life and death. She responded: we always ask ourselves if we would be surprised if our patient died tomorrow and I would not be surprised. I think she may have a few more weeks.
She was honest and told us her opinion about my cousin's situation.
And that was what happened.
My beloved friend died a few weeks later as we held her hands in her bedroom.
I will always be grateful for that doctor.
That sounds like a perfect way of expressing it. Thank you for sharing that.
Beautiful and emotional, thank you Mr Cifu.
Dr Cifu, if you please.
The combination of being an EBM/obsessed diagnostician (Dr. House?) and landing on quadrant B without evidence must be quite disconcerting! As a student of human behavior, I think it's fascinating the myriad ways people cope with existential matters, and those who work with the dying say that we tend to face death in the same manner we face life, or as somebody put it, "The way we do one thing is the way we do everything." I'm working on the way I do everything, in the hopes that by the time I face death, I've finally got it right!
Well said. Thanks.
Beautiful essay.
Thanks.
--A
Thanks. Insightful. I hope to know and for my doctor to know. Healthy at 80, I feel I have had my share of life and am thankful for it; I hope to have more and not painfully more.
Oh goodness.