Why don’t doctors talk about death with their patients?

The failure of doctors to talk to their patients about end of life decisions perplexes me.  This gap in vital communication results in poor care, uncontrolled pain, futile treatment and death in hospital or nursing home, where no patient wants to be.  Certainly, for oncologists, every patient they see is concerned about dying and by not opening the topic it leaves each isolated.

I have generally taught my students that this failure results from a “culture of cure.”  Doctors and patients focus so hard on treatment, whether its fighting cancer, heart disease or even Alzheimer’s, that they ignore the reality that all life eventually ends.  Lost is the opportunity to plan for end-of-life needs, which can deny the patient and family a gentle passing.  Doctors falsely see death as the great enemy, instead of suffering and disease. Often the illogical emphasis on cure at any cost is key to poor end-of-life communication.

Recently I have been considering a slightly different perspective on this problem, based in the works of psychoanalysts, Sigmund Freud and Otto Rank, and how they saw human personality.  They proposed that man is, in a sense, a demi-god.  Half god and half-animal.  By god, they did not mean infinite and all-powerful.  Rather they observed that man has characteristics that are god-like and therefore unique among all creatures.

These god-like traits include the ability to imagine something in the abstract and then make it happen.  For example, one can dream of a two-floor red house, and then build it or envision a five layer chocolate cake and then bake it. Second, man can, in his mind, travel to any time in the future or the past, including the world before or after his life. He can also move his mind to any place in the Universe that he imagines.  Finally, at the most basic level, man is self-aware of his own existence and mortality. As we understand life on this planet, these are remarkable and special god-like abilities.

On the other hand, man is an animal. He is born, grows, can be injured, ages, and gets sick.  He eats, has sex, shivers when a frigid wind blows and has to move bowels and urine. Finally, eventually, the animal that is man dies.

Psychoanalysts believe that emotional trauma in human life is because man is not really a god and is something more than just an animal. He is a demi-god and being a demi-god is hard.  He can create and appreciate goodness, enjoy the wonder and awe of each day; teach, learn, and dream, but at the same time, he can see into the future and knows his fate.  His mind can conceive flying through the air, staying awake for days or living to be 10,000, but he is denied by the limitations of his flesh.  This results in life long stress and in order to cope man uses various psychological strategies, including repression and denial, to focus on each day and each moment and not go truly mad.

When someone becomes ill with a life threatening illness such as cancer, their ability to deny the animal part of their existence may collapse.  Suddenly they are less god than ailing beast. This can cause terrible anxiety, confusion and depression, as their personality is threatened by physical deterioration and critical coping mechanisms fail.  At these critical times, the support of a physician who understands the core balance of the human condition can be most valuable.

However, it seems to me that doctors do not talk about death to their patients, not because they do not care, but because doctors do not know how to deal with the god, they only understand the animal. They are scientists who base decisions on anatomy, physiology and chemistry, which are the building blocks of the biological body.  Even psychiatrists talk about chemical imbalances causing depression.

Doctors receive almost no training on the mechanisms, drives and weaknesses of the mind, where-in lies the god-like powers of man.  Like veterinarians who are unable to talk to their patients, doctors continue to focus on the body and despite their best efforts, do not offer desperately needed connection and support.  Paradoxically in their efforts to heal, they drive the body to a point that causes unneeded suffering.

As long as the sole focus of physicians is on the animal body of man, they will have great difficulty having the kind of vital discussions needed to assist their patients at the end-of-life.  On the other hand, this offers a nearly infinite opportunity to reach out to the hearts of their patients. By connecting and supporting the primary emotional needs of the demi-god soul, physicians can help patients to live better.  This will require not only physician awareness of the possibilities, but training about drives and coping mechanisms.  Medical education needs to recognize that by understanding the primal needs of patients, and the complex psychic battles which each of us face, doctors can help provide quality life, even at its end.

James C. Salwitz is an oncologist who blogs at Sunrise Rounds.

email

Comments are moderated before they are published. Please read the comment policy.

  • James deMaine

    Physician educator Roger Bone in the Annals of Internal Medicine wrote about his own dying and would likely agree with your comments. In a way, we’re all in denial about our own mortality thus finding it hard to delve into a discussion of our patient’s mortality. It takes time, emotional maturity, and a real interest in exploring this area. For more, see http://www.endoflifeblog.com/2011/09/can-we-talk-about-death.html

  • Jenna Smith

    >>Like veterinarians who are unable to talk to their patients, doctors
    continue to focus on the body and despite their best efforts, do not
    offer desperately needed connection and support.>>

    No, not like veterinarians at all. Veterinarians spend a lot of time talking to clients about death and, perhaps even more important, quality of life. It’s not a favorite topic, but it’s part of our training and spend a lot more time than the average physician. BTW, though we are aware our patients can’t talk, neither can many suffering human patients at the end.

    • http://twitter.com/PJB956 Pamela Brooks

      I wish your statement about veterinarians were true for all but it is not. I have only met one vet in my 30 plus years of owning pets who would talk about death.

  • http://twitter.com/PJB956 Pamela Brooks

    I don’t think medical professionals are trained to talk about death. I experienced great frustration with the death of my mother – even though her doctor accurately predicted her date of death he would never discuss it with her. My veterinarian – who I really like – more recently could not talk to me either. She at least referred me to another vet who makes house calls who could talk to me. How long before these folks are trained properly and can accept that death is part of life. I hope it happens in my lifetime – so that I can at least go peacefully if the circumstances will allow it.

  • Joshua

    Physicians have trouble talking about death because the professional standards that exist would have us believe that physicians are to remain “value neutral.” Discussions of death involve more values-based medicine rather than evidence-based medicine (or at least an equal mix of both), and we’re better trained in evidence-based medicine.

    We need to recognize that both our own and our patients’ worldviews are informed by particular values, and it’s important to talk about that (Beckwith, FJ. and JF Peppin. Physician value neutrality: a critique. 2000. Journal of Law, Medicine & Ethics. 28:67-77.)

  • http://twitter.com/RHR_Chat RHR_Chat

    For nearly 3 years, I was 24/7 caregiver for my dad (cancer and osteomyelitis).

    The oncologist and orthopedic surgeon continually told both dad and me that dad was fine. In fact, two days before his death, I was concerned about his health and telephoned his oncologist’s office. The oncologist had not even seen my dad for over six months. The only doc that routinely saw dad was the orthopedic surgeon.

    The oncologist’s office told me “he is fine” and “we will see him next month.”

    My dad died peacefully at home two days after that telephone discussion.

    The EMTs came to our house after the 911 call and asked who dad’s doctors were. I gave the names of both the orthopedic surgeon and the oncologist. No doctor examined dad to determine cause of death. The oncologist signed the death certificate and, in so doing, attested that colon cancer was the cause of death.

    Apparently that phone call two days prior to dad’s death was inaccurate. I suspect that I knew dad would eventually die. But, if the oncologist had known that he would imminently die from cancer, he should have told us.

    We would never have allowed the orthopedic surgeon to aggressively treat dad’s foot and thereby cause osteomyelitis. (I later learned that bones do not heal well when patient is receiving chemotherapy).

  • Wy Woods Harris

    This one gets Wy’s WOW Award so why don’t we run this one in the social media race.

  • meyati

    it took me 2 years to get a DNR, because the hospital health system says the doctor has to issue it, and my doctor won’t-Everyone immediately wanted to know if I wanted to meet with a counselor. I finally snapped-and told them that I have been capable of committing suicide without their permission. I have cancer now- and the wanted me to fill out my wishes–what music I wanted in my last days, holding hands-while pulling the plug is an option-I couldn’t fill that out because a patient needed a DNR—-I began cussing and screaming. I just wonder how this red tape affects the health of other patients and their families. By the way, I ended up cussing like a bosun mate- The counselor finally got a doctor to sign off- then I could do my paper work for my hospice care—I’m still alive.

  • f. lusu

    when i filled in the new patient forms at a dr. office and there was a paragraph about bringing in a living will. when i was ready for the discussion, i brought in the paperwork and the dr. talked to me. i feel relieved that i was given a wake up call in time to make a difference in my care. i think it’s a very good idea for dr.s to do this one simple thing to begin a conversation. it might be the best opportunity a reluctant dr. has to initiate such a discussion with his patient.

  • Patty

    So many doctors rely on the nurses to have that kind of talk with families and patient…especially when those patients are in a LTC facility. I am a nurse in LTC facility and not so long ago had a doctor yell at me saying ” Don’t. You nurses teach the families and patients about the dying process?” geezzz..we live it, breathe it and work every single day with the death and dying .. Especially in a Long Term Care Facility. I think doctors are very uncomfortable with this because its almost like a defeat.. They don’t usually deal with t hat end result.. So outta sight outta mind so to speak. Maybe MDs need to take some Continuing education on death and dying. As a nurse we have to take these continuing education classes and obtain CEU’s every two years to keep our license.

  • petromccrum

    Great article. I can attest to the lack of communication regarding end of life issues. When I directly questioned my husbands doctor about his prognosis he just kept telling me “its bad” What does that mean. I was discouraged to transfer my husband to hospice: “we want to try one more treatment” knowing full well it was not going to work. After my husbands passing I complained to his doctor about his lack of accurate information, etc. This situation was made MUCH worse than necessary due to the lack of communication and also the lack of compassion.

  • katerinahurd

    I have a different perspective on who plays the demi- god. I believe throughout their training at medical schools future physicians are trained to treat and restore the physiological health. By doing so, they deny psychological health that is wrapped around physiological health. Their denial of death stems from their denial to become aware of the quality of life when approaching death and thus being indifferent to the importance of spiritual health. Do no harm extends to the protection and respect of the spiritual health of their patient

Most Popular