Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

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

James C. Salwitz, MD
Physician
February 21, 2013
134 Shares
Share
Tweet
Share

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.

Prev

Medical education: Reform the investment of tuition and time

February 21, 2013 Kevin 2
…
Next

Why physicians tend to decline CPR and other heroic measures

February 22, 2013 Kevin 6
…

Tagged as: Palliative Care

Post navigation

< Previous Post
Medical education: Reform the investment of tuition and time
Next Post >
Why physicians tend to decline CPR and other heroic measures

More by James C. Salwitz, MD

  • Each line on the radiology list is a patient’s line in the sand

    James C. Salwitz, MD
  • The broader mission for hospice care

    James C. Salwitz, MD
  • Is the medical profession at its end?

    James C. Salwitz, MD

More in Physician

  • The erosion of patient care

    Laura de la Torre, MD
  • Navigating adulthood in the digital age

    Eleanor Menzin, MD
  • The power of business knowledge for medical professionals

    Curtis G. Graham, MD
  • Using the language of art to create work-life balance

    Sarah Samaan, MD
  • Lively communication in the service industry

    Deepak Gupta, MD
  • Reigniting after burnout: 3 physician stories

    Kim Downey, PT
  • Most Popular

  • Past Week

    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • Inside the grueling life of a surgery intern

      Randall S. Fong, MD | Physician
    • I’m tired of being a distracted doctor

      Shiv Rao, MD | Tech
    • Pediatricians grapple with guns in America, from Band-Aids to bullets

      Tasia Isbell, MD, MPH | Policy
    • Understanding intersex health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • AI-driven diagnostics and beyond

      Michael Kirsch, MD | Tech
  • Past 6 Months

    • Medical gaslighting: a growing challenge in today’s medical landscape

      Tami Burdick | Conditions
    • I want to be a doctor who can provide care for women: What states must I rule out for my medical education?

      Nandini Erodula | Education
    • Balancing opioid medication in chronic pain

      L. Joseph Parker, MD | Conditions
    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • Mourning the silent epidemic: the physician suicide crisis and suggestions for change

      Amna Shabbir, MD | Physician
    • Misunderstandings about opioid use disorder

      Amy Baxter, MD | Conditions
  • Recent Posts

    • Understanding intersex health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • The erosion of patient care

      Laura de la Torre, MD | Physician
    • Debating the role of psychiatric assessments in medical decisions

      Christian Youssef & Francisco M. Torres, MD | Conditions
    • Navigating adulthood in the digital age

      Eleanor Menzin, MD | Physician
    • 5 things to know about weight from a bariatric surgeon

      Maria Iliakova, MD | Conditions
    • Out-of-office infusions in oncology care [PODCAST]

      The Podcast by KevinMD | Podcast

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 12 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • AI Not Ready to Replace Radiologists Interpreting Chest X-Rays
  • Study Confirms Better Survival for HPV-Positive Cervical Cancer
  • FTC Sues Anesthesia Group and Its Private Equity Backers
  • Inmates Escape From Hospitals in Recent Spree
  • 'The Last Straw' Driving Workers Out of Healthcare

Meeting Coverage

  • New Schizophrenia Treatments Are Coming: Don't Panic
  • Loneliness Needs to Be Treated Like Any Other Health Condition, Researcher Suggests
  • Stopping Medical Misinformation Requires Early Detection
  • AI Has an Image Problem in Healthcare, Expert Says
  • Want Better Health Outcomes? Check Out What Other Countries Do
  • Most Popular

  • Past Week

    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • Inside the grueling life of a surgery intern

      Randall S. Fong, MD | Physician
    • I’m tired of being a distracted doctor

      Shiv Rao, MD | Tech
    • Pediatricians grapple with guns in America, from Band-Aids to bullets

      Tasia Isbell, MD, MPH | Policy
    • Understanding intersex health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • AI-driven diagnostics and beyond

      Michael Kirsch, MD | Tech
  • Past 6 Months

    • Medical gaslighting: a growing challenge in today’s medical landscape

      Tami Burdick | Conditions
    • I want to be a doctor who can provide care for women: What states must I rule out for my medical education?

      Nandini Erodula | Education
    • Balancing opioid medication in chronic pain

      L. Joseph Parker, MD | Conditions
    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • Mourning the silent epidemic: the physician suicide crisis and suggestions for change

      Amna Shabbir, MD | Physician
    • Misunderstandings about opioid use disorder

      Amy Baxter, MD | Conditions
  • Recent Posts

    • Understanding intersex health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • The erosion of patient care

      Laura de la Torre, MD | Physician
    • Debating the role of psychiatric assessments in medical decisions

      Christian Youssef & Francisco M. Torres, MD | Conditions
    • Navigating adulthood in the digital age

      Eleanor Menzin, MD | Physician
    • 5 things to know about weight from a bariatric surgeon

      Maria Iliakova, MD | Conditions
    • Out-of-office infusions in oncology care [PODCAST]

      The Podcast by KevinMD | Podcast

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

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

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

Loading Comments...