In the end, we just have to talk about it

By Robert N. Jenkins
Published May 29, 2007

CLEARWATER — The evening's topic at The Hospice of the Florida Suncoast had been set weeks earlier: "Communicating about care at life's end." Yet the audience question closest to that subject didn't come until near the finish of the two-hour session.

Does it seem, transplant surgeon Pauline W. Chen was asked, that death "is this inescapable reality that we're all on the same collision course with, but that we don't want to talk about?'

"I think, at least in Western culture, there are certain cultural precedents for not talking about death, " offered Dr. Chen. "Freud says that in our subconscious, none of us believes we are mortal, but to completely deny that, which is what I think we end up doing, is not that healthy."

In a roundabout way, the discussion had actually returned to Chen's opening comments on the vast topic of humanity vs. technology. Reed-slim and soft-spoken, she said:

"In the almost four months that my book (Final Exam: A Surgeon's Reflections on Mortality) has been out, I have been asked one question dozens of times:

"Isn't being compassionate at odds with being a good doctor? Or, more specifically, how can a doctor care about dying patients and still get the job done?

"There is a belief that . . . in order to be a competent doctor, you have to maintain some distance from your patient."

Chen rejects that theory and indeed has been honored by one of her alma maters, Yale University, for emphasizing "kindness and care in an age of advancing technology." But she told her audience of about 50 health professionals why the theory of unconcerned doctors has validity.

A multimillon-dollar study conducted in the 1990s asked how doctors do when it comes to caring for the dying.

"The initial findings were dismal, " Chen related.

"A majority of physicians had no idea what their patients wanted in terms of resuscitation and . . . more than half of hospitalized patients who remained conscious at the end of life complained of moderate or severe pain, at least half the time."

To remedy this failing by doctors, Chen continued, the researchers hired "specially trained nurses who talked to the patients and their families about their diagnoses . . . and their preferences regarding treatment. The nurses then communicated regularly with the physicians and with hospital staff.

". . . After two years, the researchers examined the results of these active interventions and what did they find? No notable improvement."

Among the possible explanations that have been advanced, Chen said:

- "Physicians will continue aggressive therapy in order not to dash a patient's hope.

- "Doctors have become so specialized that no single physician is ultimately responsible for facilitating end-of-life choices . . .

- "Patients, too, may be in part responsible, since some may hesitate to be assertive, fearing negative repercussions from their doctors.

"I can nearly guarantee that every one of (these doctors) really believed - probably even passionately so - that they were doing the best they could. They were treating the diseases they saw and interpreting and analyzing the clinical data they received.

"And they were doing it with little communication with their patients, the very people they had set out to help . . ."

"Every day, " she added, "doctors go about their work faced with uncertainty. There's not a single thing we do - diagnose, prescribe, deduce or operate - where we can be absolutely confident 100 percent of a patient's outcome.

"We take nothing for granted (yet) uncertainty is a part of our daily lives . . .

"In order to provide the best for terminal patients, doctors need to be comfortable with the mystery of death, the lurking possibility of therapeutic futility and the nagging doubts regarding one's own clinical prowess . . .

"We must be able to put ourselves - body and mind - in someone else's shoes, and we must understand another's definition of dignity."

Instead, "We distance ourselves so much from patients that in the end, we fail not only them but also ourselves."

Chen believes that medical professionals "have a great privilege at the end of a patient's life . . . to create an environment where patients can express their fears, ask us anything they want, or to just be by their side so that they are not alone."

In answer to a question, Chen said that in the 10 years since she finished medical school, there have been positive changes in health care professionals' attitudes toward the dying.

"I think people have been talking more about talking (to patients) about it . . ."

But there needs to be further progress, she says:

"We should acknowledge the fact that (a) death is difficult, (b) talking about it is really hard, but (c) maybe we can try. We can commit these individual acts of courage and try - push ourselves to try."

Robert N. Jenkins can be contacted at (727) 893-8496, or bjenkins@sptimes.com.
 

For more information

- The Hospice of the Florida Suncoast is at 5771 Roosevelt Blvd., Clearwater; (727) 586-4432; www.thehospice.com/.

- Final Exam: A Surgeon's Reflections on Mortality, by Pauline W. Chen, 268 pages, Random House, $15.09 online.

For more information

- The Hospice of the Florida Suncoast is at 5771 Roosevelt Blvd., Clearwater; (727) 586-4432; www.thehospice.com/.

- Final Exam: A Surgeon's Reflections on Mortality, by Pauline W. Chen, 268 pages, Random House, $15.09 online.

[Last modified May 28, 2007, 13:51:16]