Wrote a thinker, “When your time comes to die, be not like those whose hearts are filled with fear of death. Sing your death song, and die like a hero going home.”
As we reach our 50s, it’s common to start worrying about our mortality. It is implied that, faced with the thought of death, “believers” differ from “atheists.” For those who believe in a life after death the thought of death is, more often than not, accepted with equanimity as there’s much to look for beyond the grave. For atheists, on the other hand, the grim reaper brings everything to a “dead end.” They have only their past to haunt them and rue for.
An agnostic on his deathbed wrote, “I have been an atheist all my life. Now, on my deathbed, I feel anxious about my own mortality. It is scary to suddenly feel like there isn’t a God looking out for us and that there will just be nothing after we die. The thought of Hell also terrifies me!”
In a recent article in the Journal of the American Medical Association the lead author says that when researchers talked about life expectancy with 28 primary care providers, clinicians described several barriers that keep them from talking freely about death with their patients including time constraints as well as a lack of confidence in tools commonly used to predict how many years patients have left. Discussing about death can be difficult and uncomfortable. We don’t have an accurate sense of how much longer our patients are likely to live. This may lead us to make poorly informed medical decisions. Many decisions in primary care require a complex balancing of the potential benefits and potential harms and the need to tailor medical decisions to patients individually.
To get a sense of how primary care providers think about incorporating life expectancy into medical decisions, researchers interviewed 28 physicians in a large group practice in rural, suburban and urban settings. 25 percent of their patients were older adults. These primary care practitioners had only vague conjectures about life expectancy in several clinical scenarios which resulted in poor balancing of prognosis against various other factors in final decision making. In particular, doctors are more reluctant to stop preventive care and talking of death in younger patients with a limited life expectancy for uncertainties abound. By the time patients reached their 80s and 90s, however, clinicians said they tended to talk more directly about dying and feel at liberty to focus more consistently on addressing directives and goals of care with their patients.
There is a vast gap between the approach of physicians in the US and doctors in Goa as far as talking of “impending” or “sudden death” is concerned even in high-risk cases. In the US physicians are forthright. Further, they feel it is their bounden duty to inform their patients at risk about the adverse prognosis lest they face the prospect of being sued in case they failed to adequately inform about the likelihood of “death” as per available scientific evidence.
Here in Goa, regrettably, the scenario is altogether different. Recently, a patient of mine referred to the Goa Medical College was awaiting a high-risk “coronary by-pass”. The concerned team of doctors, in all good faith, mustered courage and “told the patient and family about the dismal prognosis and possibility of death during surgery or in the immediate post-operative period. However, if successful, the same surgery could give the patient a new lease of life”, they added. It so happened that on the very next day, even before the patient was wheeled to the operation room, he died. The relatives were furious. “Patient had died of emotional shock,” they alleged “after all the gloomy doctors’ talk about death.” Recently, a patient of mine with a “dilated cardiomyopathy” was in gross heart failure in a precarious condition. With all the finesse I could muster I apprised the patient and family that he could die any moment. To my bad luck, the patient passed away the very next day. The relatives stormed my clinic with threats and abuses. To them I was the culprit. “Notwithstanding the seriousness of his illness the patient had died prematurely” they alleged, “after my insensitive blah-blah!”
There’s a saying, “Death is more universal than life. Everyone dies but not everyone lives.” Still, we doctors face a piquant situation to openly talk about death with our patients. Providing good end-of-life care requires, for one, both an understanding of how patients and families experience the dying process and a sensitive communication style. Physicians must conduct thoughtful discussions in which most decisions evolve comfortably and without controversy.
Here are a few rules for doctors, “First, novices must observe experienced clinicians address these issues with their patients. Second, our skills and comfort level increase only through repetition and practice. Third, we must be open to feedback from our patients and their families. Finally, we must all re-shape views to acknowledge death as a natural and inevitable last step in the progression of aging and of disease. Providing care for a dying patient is challenging and, when done well, gives a gratifying experience to the physician. To help someone die in comfort, peace and dignity is to give one final gift of life.
(Dr. Francisco Colaço is a seniormost consulting physician.)
