A Doctor’s Duty, When Death Is Inevitable

A letter to a physician may not seem like a “personal health” matter unless the problem it addresses – whether doctors abandon patients who are dying – concerns you or someone you love.

The letter that appears below was written by the husband of a woman whose oncologist had cared for her for nearly seven years, and then abandoned her, her husband writes, in the final weeks of her life. A copy of the letter was sent to Dr. Diane Meier, director of palliative care at Mount Sinai Medical Center.

Dr. Meier told me, “I have seen this happen hundreds of times, causing profound hurt and injury to the patient and family that compounds the losses a thousandfold.”

The oncologist had been the patient’s lifeline for years, and the doctor’s behavior distracted the patient “from the important family and existential work she should have been attending to while she was dying,” Dr. Meier said.

“Patients wonder what they did to offend their doctor, why they are no longer worthy of attention,” she continued. “And, of course, patients do not realize that since they ‘failed’ therapy, the doctors feel they ‘failed’ the patient. When patients are so sick, the doctor-patient relationship is deeply personal and vulnerable and unequal. Doctors need to know the cost of this behavior for their patients, whose interests they are sworn to put first.”

What follows is pure speculation, a form of pop psychology. I believe this speculation coherent and consistent with my observations over the past 30 years.

All physicians keep “score”. We privately celebrate our successes and agonize over our failures. For me, making a great diagnosis which leads to the patient improving causes a celebration (admittedly an internal celebration). I am likely to “present” this success to colleagues. I revel in my cleverness, or serendipity. And the patient benefits.

I also count success when when I help a patient with smooth, respectful palliation. I often must deliver bad news to patients. At these times I grade my technique and try to evaluate the patient’s response. Helping patients through these difficult times gives me equivalent satisfaction as the “great diagnosis” described above.

I count failures. When I botch a conversation (and I do, because we all do), I replay that conversation repeatedly, trying to understand how to avoid my error. When I miss a diagnosis, or have a diagnosis delayed I agonize. All physicians seem to have this attribute of obsessing over their own perceived errors.

Oncologists have a difficult job. They are trying to defeat cancer. Now some cancers are beatable (Hodgkin’s, some breast cancers, some leukemias, early colon cancer, some prostate cancer), some cancers manageable, and some very resistant to any treatment.

When oncologists have success, especially against more difficult cancers (like lung cancer) they deservedly enjoy the success. They mentally move that patient in to the unexpected success column, a column which ratifies their specialty.

When a patient from the success column relapses, the oncologist has a difficult psychological blow. He/she had invested psychologically in the patient’s success, and now he/she must confront the cancer’s victory.

Some oncologists find these situations difficult and use avoidance as a psychological defense mechanism. One can easily argue that this avoidance represents abandonment, but I do understand why it happens. Oncologists spend their lives trying to beat cancer, and that must take a psychological toll.

Unfortunately, the patient can suffer psychologically in this situation. This NY Times story describes the patient’s view.

Our oncology fellow now all spend at least 1 month on the palliative care service. Many embrace palliation as an extension of their contribution to patient care. But we must remember that this concept is “new school”, and many oncologists are still “old school”. We would like to teach these “old dog new tricks”. Some teaching is very difficult.

Related posts:

1. Not all screening helps patients
2. On difficult patients
3. Prostate cancer screening
4. More on personality and medical school success
5. How do patients define quality physicians?

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