How Long Do I Have?
Posted by WhiteCoat on March 13, 2008
Sometimes being a doctor really sucks.
I do some tests on a patient. One test leads to more tests. It becomes pretty obvious that the patient has metastatic cancer. Hits all over the place: brains, bones, liver. She had a history of lung cancer in the past and thought she had it beat. She didn’t.
Even when I know it’s cancer and I know the prognosis isn’t very good, I still tell the patient that we have to do more tests to make sure we know what’s going on. Part of me doesn’t want to make the patient give up hope. Part of me wants to “ease” the patient into the diagnosis – give them time to accept it instead of just hitting them with a load of bricks all at once. Part of me just wants to pass the buck to the family doc who knows the patient a hell of a lot better than I do.
I walked into the room with the patient and a couple of family members sitting there. I went through my spiel about the uncertainty of the diagnosis and the need for more testing. This time the patient saw right through my little routine. She looked me straight in the eye and asked “So how long do I have?”
Talk about being left speechless. It’s like she picked up that ton of bricks I just hit her with and she threw them all back on top of me.
“Well … um … if it turns out to be cancer … um ….”
It suddenly got warm in the room and I could feel my face getting red.
“I can tell its cancer. How long do I have?”
Instant whirlwind inside my mind — I’m not supposed to be doing this type of thing. I save people. Well, sometimes people die, but at least I code them first. Well, most of the time. Stop going off on tangents, dammit! I don’t have a time line. I’m no oncologist.
All that blurts out of my mouth is “Well, it’s tough to say …”
That wasn’t going to cut it. They just kept looking at me. My face was getting even more red. I knew that all they would remember from this whole ED visit would be the next words out of my mouth. What do I say? Do I want to be optimistic and then have them be mad at me if she dies suddenly? Do I want to underestimate how much time she has left and then have everyone remember me as “the doctor that gave her three months to live … three years ago”? Waffle, dammit. How do I waffle?
“If it is cancer, depending on the type of cancer, about half of the people with metastatic lung cancer will die within six months.”
They didn’t hear all of the qualifiers in my statement. All they heard was “six months.” At that point some giant hand turned over the hour glass with six months’ worth of sand in it. Everyone in the room looked at the patient. The patient looked down at her bed.
I wasn’t needed in that room any more. Besides, a patient with chest pain just got put into another room.
Yep, sometimes being a doctor really sucks.
truth_chaser said
Somehow I feel that your problem of being embarrassed or nervous to tell the patient how long she has to live is overshadowed by the fact that this person is dying. I guess I just don’t feel sympathetic for you. But in a way, your blog did touch me.
sat said
Why does it always have to be someone saying they don’t feel sorry for a doctor whenever one talks about how hard it can be to deal with life and death all day. No one’s saying the woman dying isn’t sad, but you try to imagine having to tell someone how long they have to live every day and not even being able to vent about it because someone’s going to say “I just don’t feel sympathetic for you.” How come sympathy and caring is only supposed to be the purview of doctors while the general public gets to be as uncaring as they want to be. I don’t think he’s saying to lose sleep crying for him, but in order to do a job like this you have to have the ability to talk about how difficult it can be to deal with this kind of thing day in and day out. The internet is just one place that a doctor can do it anonymously.
Bostonian in NY said
I had an awkward situation with a preceptor of mine similar to that…on my first clinical day that I was allowed to talk to patients. Pt had been bounced around between 4-5 different docs without a straight answer as to what the softball-sized mass under his arm was, previous cytology was negative for cancerous cells and his PMD had treated with a couple courses of antibiotics to no avail. Two surgeons wouldn’t touch it, PMD wanted to keep going with different antibiotics, it was pretty obvious that it was a lung CA met…and while all of his docs new that he had lung cancer with pleural invasion, everyone had punted on giving a prognosis. The patient and his son were pretty aggravated over the whole situation but when the time came to give the prognosis, they couldn’t understand my preceptor’s accent…I punted too and let them figure out what he was saying because I didn’t want to put myself in that sort of position. It was one of the most awkward points in my training to date, and I’m not looking forward to when I have to do it in practice.
bitterbarn said
heh, Do you know why being a doctor sucks?
Because medicine sucks. When I say “medicine” you know what I mean. The institution that embodies the professions of physicians MD’s and DO’s are sub-par. We (the american public through millions and millions of dollars at “medicine”; every year. we have been throwing our money away on medicine for a long time. I am not talking about salaries. The salaries in medicine are minute compared the donations to the NIH and various researching bodies every year.
The question my dear Doctor is this. How Much Money?? How much money shall we through at cancer and the legaslatlative commercial protection of MD’s and DO’s. UNTIL you find a cure? The last Cure Medicine came up with was Penicillin. Oh sure we cut stuff out of people and reroute their cuts. but CURE, Medicine has failed us. If you work in it you cannot deny it.
physicians sit on the Boards of all major insurance companines and hospitals and they (physicians) allow the atrosities that ail our healthcare system. Maybe its time you hand over the reings to someone who cares. someone in Allied Health probably, pharm or Nursing.
sat said
If doctors didn’t care they wouldn’t sacrifice their youth, time, and sleep to try to help people. You are MUCH healthier now than people 100 years ago due to medicine and public health, but all anyone can do is complain.
Cali_Yalie said
How apropos you wrote about this! Today I had a patient that, through a series of punting, I was left holding the ball, and had to tell her family that she has a very large lung mass. It was absolutely horrible. I would never purposefully omit pertinent diagnostic findings or convince someone of a diagnosis that wasn’t truthful. I don’t understand how this occurred. And to think, they were all under the belief she had “pneumonia.”
Brandy Roth said
It seems some of these comments are pretty harsh. It took me a while, but I finally get that doctors are just people trying to help us in very complicated situations.
Maybe having several loved ones die (grandma, aunt, father, little brother) before I got too far into my 20’s put me in a more realistic boat. We’re all going to die. The American Lifestyle (not the health care industry or insurance companies) is more to blame, certainly not doctors. Don’t ask the doctor about his salary, ask my dad and aunt why they spent thousands on cigarettes and alcohol, hi fat foods, and exercise equipment that gathered dust. Ask yourself what that trip to the drive-through and those gallons of soda are doing to your body.
Even when you get some disease completely by genetic chance, like my little brother, I don’t know … it just seems like we need to get over death, it’s not the worst thing that could happen.
sat said
Thank you! I wish more people could see things like you do.
frozen said
I would say it sucks even more to be the patient.
Really, I don’t know that there’s any good way to deliver such news. I don’t know that there’s any way to accurately prognosticate.
I think what you said was fine. I hope you also threw in an “I’m sorry to be giving you this news.”
If you felt nothing and thought this whole situation was a piece of cake for you to deal with, I would worry about what kind of person you’ve turned into. The fact that it’s hard just means you’re a human being who’s still capable of feelings.
truth_chaser said
Death isn’t the worst thing? What, then, is the worst thing?
Ladyk73 said
Oh my…..it looks like your recent NPR fame has sent some anti-docs to your blog!
I think you were in a tough situation, you are not a cancer specialist. I would not want to have to give someone such an awful diagnosis in an ER or clinic. I mean…their primary physican or oncologist would be the ideal person.
I mean, I would hope no one would sugar coat a diagnosis just to punt to another doc. Maybe a good approach would be: “It appears you have a sign or symptom of a serious disease” Explain the disease, actively refer the patient to specialist, and then offer best outcomes, worse outcomes and the less likely but not as serious deferentials? Just a thought.
I am glad I am not in a profession that would have to tell someone they had a terminal disease. Yikes!
I think you handled it very well. You are human, and a very good one at that!
MM said
Yes, that’s tough… Some people get frustrated because they want nothing but the truth and feel their doctor is walking circles around the issue while others cannot handle the truth. How can you know?
The question of “How long?” is of course a loaded one, but maybe she wanted to have a general idea: was it weeks or was it months?
You did the best you could.
Dr. Val said
It’s very difficult giving bad news… I think it’s ok to say “I honestly don’t know” when patients press us for answers we can’t give. I might have said what you did though…
phuonglili said
Congratulation! both of your blog, and this post are high ranked in
“The top blogs of the day” report
Chrysalis Angel said
I feel for you. It has got to be a very hard thing to give that news. I think you will find a lot of the patients already know what they only need you to verbalize.
My doctors didn’t want to say the “CA” word. I had to use it first. His eyes just widened and he paused as I waited. He then looked almost relieved – there it was out in the open, now let’s deal.
Louis said
You can be my doctor anytime.
A tough article to read.
Had to be tough to write.
Jamie said
How hard! I, too, wish that you were my doctor. Actually, I wish that you were my husbands doctor. Our current doctor will tell us there’s no hope, but he won’t give me a timeline or an idea of what to expect. It’d be easier to deal with if I knew.
If you’re having difficulty getting answers from your doctor, I have listed several medical reference sites on my “Links” page that you may be able to use to find more information. Good luck to both of you.
SeaSpray said
Awww…I know that must be so difficult for doctors. I think you handled it well.
This was a beautifully written post on such a sad and frustrating subject.
This post also hits home because our aunt who was diagnosed with breast CA in September 06 had it spread to her groin and neck and liver. She was recently informed that it is no longer in her neck or groin but still in her liver. They said it is no worse but it is no better. They were going to give her a rest from the treatments (she’s so thin) but within a few days she wasn’t walking right or pronouncing her words right. At first they said it must be a virus go see your PCP but he was out of town. Good thing because the cancer doc said to come in and after another test discovered that she has lesions on her brain. So now she is getting treatments again and getting stronger…a little stronger.
I thought she looked a little on the yellow side when I saw her a couple of weeks ago. She has been enduring all this for almost 18 months.
SeaSpray said
The oncologists do tell her that there is more they can do whenever she gets bad news.
alex said
during my first few weeks as a nurse, I found myself caring for a Spanish speaking patient who was dying of cancer. her family withheld this information from her even though she was in home hospice care. she was admitted to the hospital for an unrelated matter and her family failed to tell us that they were keeping the severity of the patient’s illness from her. well, I was the only Spanish speaker on the unit that day, and the patient asked me point blank what was going on. I had no choice but to level with her. it was truly horrible. I’m not too proud to admit that we both cried more than a little.
as a nurse, I never expected to be in that position. when all was said and done, though, I was glad that I had not lied or deflected. I understand that there are cultural differences in how such news is handled, but I felt that being truthful was the only way I could give this woman the respect she deserved.
Anonymous Surgeon said
Considering the fact that it really was entirely inappropriate for a patient to be coming to the ED for a chronic, albeit terminal condition that really could be MUCH better addressed by her oncologist and PMD, I think you did great. Spitting out the necessary truth about a terminal condition is always hard, especially without knowing the patient or their family dynamics. I think it is best to talk about averages without removing all hope, but yet be realistic enough to let the patient and their family know that it is time to “get their affairs in order.” Some of the worst arguments I have had were with families that didn’t want “Dad” or “gramma” to know their diagnosis. Giving time estimates are near-impossible; the distribution around the mean varies so much person to person that I usually have to give a little speech about “average” and how there are so many trials and new treatments being discovered every week.
Really, these kinds of discussions are what oncologists deal with every day. Just like you can take care of asthma, chest pain, and a dislocated shoulder without batting an eye, that’s what these brave (and usually compassionate) men and women do all the time.
The Wife said
My husband had his bladder removed from bladder cancer in July 2005. THe cancern was not through the bladder wall and was not found in the lymph nodes. A few months later, it was found in his urethat and that was removed. He has been cancer free since then. This past fall he had back pain that was attributed to a dislocated tail bone and ultimately arthritis. Two weeks ago, we found the real problem was metastatic bone cancer in the pelvic area and spine. We also found nodules in both lungs “too numerous to count”, a suspcisou area in his liver, and a small 4 cm mass in his abdominal area. We are going with radiation to treat the pain and them looking at chemo. When we asked the oncologist how long he would live, he just danced around the answer and never gave us one. I know the prognosis is not good, but it would really help if he had been more honest and open with us so that we could somewhat plan.
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virginia597 said
Ah, that sucks ass. I have to agree with Anonymous Surgeon and MM here–you did the best you could, and, although it may not feel like it, it could’ve gone much worse. It sounds like the patient had a pretty firm grasp of the severity of the situation, or she wouldn’t have even asked. My dad died of metastatic lung cancer just a few years back, same situation (in that he’d thought he had it beat). I was actually in school when he received his prognosis, so I can’t really tell a long story about it one way or another, but I know that we never would’ve gotten through the whole ordeal without honesty and caring from all his doctors.
From your description of her, I would guess that the patient was grateful to have gotten an honest answer, at the very least.
On a side note, I can’t help but recommend (although you surely already know, and I apologize if it’s troll-feeding) that you thoroughly ignore Truth-chaser and everyone like her. I would guess it’s either poor imagination, poor reading comprehension, or weak empathy skills that produce that sort of response.
Well, at least the rest of your month is almost guaranteed to go better than that. And may you never have to do that again.
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