The Frontal Cortex

Talking About Death

Talking about death is hard, and many doctors aren’t very good at it:

Researchers who in the mid-1990s observed more than 9,000 seriously ill patients in five American teaching hospitals found substantial shortcomings in the care of the dying. More than a third spent at least 10 of their last days in intensive care. Among patients who remained conscious until death, half suffered moderate to severe pain. And fewer than half of their physicians knew whether or not their patients wanted to avoid cardiopulmonary resuscitation.

That’s from an interesting op-ed in the Times today by Dr. Pauline Chen. A big part of the problem is that nobody likes discussing mortal issues, especially if the dying person is your patient. As Chen notes, “Patient deaths, for many doctors, represent a kind of failure, and so without really thinking, we look the other way.”

Of course, this inability to confront the brute fact of death has huge repercussions. As I’ve noted before, 1 percent of medical patients account for nearly a quarter of all medical spending. Much of this money is spent on end-of-life care. In general, I think we need more hospices and less heart-lung machines. We don’t have to rage quite so hard against the dying of the light.

So how can doctors become better at dealing with end-of-life issues? I think part of the answer is literature. Many medical schools are now offering literature classes precisely because great novels and poems teach us how to talk about death. They give us a language to discuss the inexplicable. Perhaps future med students should find time for a little John Donne amid all their cramming for organic chemistry.

Comments

  1. #1 DavidD
    December 26, 2006

    As a retired neurologist who spent lots of time talking with patients about death and disabilities that many patients consider fates worse than death, may I say that this is the silliest suggestion I’ve seen you make. Intimacies like wooing women may require poetry. To be intimate with people about death mostly requires just pushing ahead, no matter how uncomfortable the physican or anyone else is about it. There are no style points awarded for that.

    Some hospital procedures require a physican to address the issue of CPR on every patient. Now doctors can get into ruts about always answering this one way, especially if it’s the intern filling out a form instead of the attending physician. I bet the study would have found better communication between doctors and patients at non-teaching hospitals, both regarding pain and CPR. Either way, the moment of CPR is not the most critical when it comes to raising the question of giving up. If someone doesn’t decide to give up until after CPR, not that much is lost. It’s those times when no one wants to give up, ever, that it’s both costly and hard on those involved.

    In my training in the ER I learned a phrase, “You can’t pace a steak”. It means that you can push a temporary pacemaker into someone’s chest, but you won’t get a heart to beat even that way if it’s too far gone metabolically. On that specific point, it’s more gallows humor than wisdom, since there’s not much left to CPR if a temporary pacemaker doesn’t work. But the phrase does punctuate something that is wisdom, that there comes a time when the only thing a doctor can do is prolong death, not prolong life, something that I don’t see being learned except by practical experience. Consider what happened with Terry Schiavo regarding other aproaches to when one is prolonging life and prolonging death. I don’t think poets are going to help that.

    Wisdom will aways come down on the side of giving up too late rather than too soon. I’m not sure how much of the current expenditures for the last days of life come from that reasonable bias vs. ignorance of the situation. I’m sure there’s some of the latter. I’m not sure it’s as significant as the technology we have for situations that are not as hopeless as pacing a steak, but might be close. Giving up at the right time is a tricky business. I don’t think those poets who committed suicide had much wisdom on the matter. At the same time, no one has perfect wisdom. Communication between the physician, the patient and others is important, but it doesn’t have to be dainty. It doesn’t have to be perfect. The pragmatism of “just do it” is as poetic as is necessary.

  2. #2 Jonah
    December 26, 2006

    Look, I certainly don’t think John Donne should be taught instead of CPR. Practical considerations must always come before poetry. And I also agree that we should also err on the side of caution. It’s hard to think of a more difficult decision than deciding that we should stop trying to save somebody.

    But I still think many doctors could benefit from literature, and not simply because they’ll become more eloquent. To put it simply, great art is about the human condition, and death is a crucial part of that condition. We often pretend that death isn’t part of life, but great novelists and poets don’t forget. (See, for example, recent works by Philip Roth and that late Stanley Kunitz.) I hope that, as medical schools increasingly use literature as a teaching tool, doctors are more willing “to push ahead” into that uncomfortable conversation precisely because they’ve thought about death via art. It’s not about sounding poetic (you can read Donne all you want and still never sound like Donne); it’s about using art to reflect on mortality, and hopefully developing a language to talk about end-of-life issues that is both pragmatic and compassionate.

  3. #3 John P.
    December 26, 2006

    i took a literature class in med school, and found it very helpful. i do think it gave me a better “language” to talk about death with patients. It also allowed me to better understand what it might be like to have a loved one who is dying.

  4. #4 Elizabeth, MD, PhD
    December 27, 2006

    From David’s post:

    “I don’t think those poets who committed suicide had much wisdom on the matter.”

    Well said, David; I like it.

    Separate from suicides, I wonder what were the ages / dying experiences of the poets and artists alluded to as insightful about life and death. How many experienced the worst aspects of aging and dying?

    People forget that medicine is practiced in a variety of circumstances around this country alone. Doctors come in all manner of beings: some more skilled, other more thoughtful; some to the point, others more sensitive. Patients are even more varied as they encompass all levels of intellect and life experiences and family situations and religious beliefs, etc.

    And what is meant by ‘compassion’ is even more difficult to grasp… indeed, there are patients who as individuals do not like to be touched.

    How to place the soothing hand is almost impossible to know without being rather sensitive as a human being oneself. A physician cannot impose his / her sense of compassion without recognizing the unique needs of a patient.

    There is no panacea for being sensitive to patients’ needs. Indeed, the ‘art of medicine’ will not be found in art, but in living life as a human being, and understanding the life of the human being who happens to be a patient.

  5. #5 Caledonian
    December 27, 2006

    great novels and poems teach us how to talk about death. They give us a language to discuss the inexplicable

    1) What’s wrong with English? (Substitute whatever language spoken in the vernacular you prefer.)

    2) Great novels and poems don’t teach us to talk about death, they demonstrate how to romanticize and obfuscate death.

  6. #6 Elizabeth, MD, PhD
    December 27, 2006

    When I was a medical student, Billy, a tweener who had been short of breath for most of his life due to cystic fibrosis, asked me: “How ____ will ______ I ______know _____ when _____ I _____am dead?”

    My immediate reply: “Billy, it will be real easy to breathe.” {Not a lot of art or religion in that answer.}

    Was it a good answer, was it the right answer, was it a real answer? Who knows?

    It was a spontaneous answer fashioned for Billy who immediately replied, between gasps for air: “That ___ will ____ be good.”

    Billy died a fw hours later afterwards. ____ Perhaps it was the answer he needed to hear.

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