Death-denial is something doctors can change

I’m not sure why so many doctors don’t get it.

Death, that is. Where in medical school, or residency, or even in non-medical life, did this many smart people get the idea that death is optional?

Theresa Brown is an oncology nurse and a writer. This weekend, her regular column in the New York Times dealt with the death-denying culture of doctors.

She begins by describing a common scenario of an elderly person suffering at the hands of a doctor who would not give up. Patients with irreversible organ damage do not get stronger in rehab, she explains. Ms. Brown then tells us how earlier palliative care could have helped this man. This didn’t happen because of a knowledge deficit. Palliative care is often mistaken for giving up rather than changing course. In the middle part of her essay, she describes the benefits of palliative care, including the fact that relieving symptoms can actually extend life. The best part of her essay comes at the end when she notes the paradox of doctoring—the charge of keeping patients alive but knowing that we always fail.

“Physicians also need to recognize that there are occasions when the patient’s fate is not, in the end, the doctor’s work. Every patient deserves care on his own terms, for each patient’s life, and death, is his own.”

This seems obvious. Why it is not so in real life baffles me.

I understand that when we are well, it’s normal to want to keep living. No well-person wants to die. It’s even hard to think about dying.

But shouldn’t doctors be different?

We are experts in health and disease. We know that any treatment comes with tradeoffs. Big tradeoffs in the elderly. Chemotherapy kills cancer cells along with normal cells; heart surgery means cutting through an elderly body, and implanting a cardiac device means removing the chance of a painless quick death or extending the lonely road of cognitive decline.

It is our job to see the obvious: No, the emaciated man will not tolerate heart surgery or chemotherapy, and he is emaciated because loss of hunger comes at the end-of-life. Which is normal.

Part of treating people with skill and compassion is having a clear-eyed view that death is normal. Death-avoidance comes with grave costs. The harm inflicted at our hands can be immense. In the elderly and ill, seeing such tradeoffs has never been more important.

There are many things in healthcare that doctors cannot change. Death-denial is not one of them. Here, we have the ability to lead, to affect positive change. All it takes is the strength to step from the crowd, see the obvious, and simply embrace the perspective that both life and death belong to the patient.

JMM