Writing for the New York Times, Daniela Lamas, a pulmonary and critical care physician at Brigham and Women's Hospital, discusses how she told one patient the truth—that he was dying—and why she wishes she hadn't.
A patient dying of colon cancer
The patient arrived in the ICU last winter, Lamas writes, with "gaunt" cheeks, a "wasted" body, and a protruding abdomen.
According to Lamas, the patient had been diagnosed with colon cancer nearly a year earlier, but he had not returned calls to follow up on his diagnosis and start chemotherapy. Now, his cancer was so advanced that surgeons could not operate on him, and he would remain in the ICU until he died.
When Lamas and the doctors in training gathered at the patient's bedside to explain his prognosis, the patient "lashed out," she writes. He seemed to be in denial about his condition, insisting there was "nothing wrong" and saying he wanted to go back home to watch a game on television that evening.
As a critical care doctor, Lamas explains that she is "familiar with denial in its many permutations" and has learned "language to show that [doctors] are on [the patient's] side, while also making it clear that things are not going to be OK."
However, she writes that doctors can be less prepared to handle "impenetrable denial," like what she was currently experiencing with her patient. "I might have left the room then," she writes. "I might have told him we were going to do everything we could to get him home, even though I knew it would be impossible… But there was a part of me, standing there receiving his anger, that wanted my patient to know the reality of his situation."
So, instead of reassuring her patient, Lamas told him, "I wish there were something we could do, but the cancer is too advanced. You're dying. It could be hours now. I don't think you will make it through the night."
The patient "flinched," she writes, and the room fell silent except for the sound of the patient's heart rate monitor. Neither she nor the other doctors in the room could say anything in response, and they soon left the patient alone.
Later that evening, the patient passed away after his family arrived to be with him. "I never had the chance to talk with him again," Lamas writes.
'I wish that I had done it differently.'
"As a doctor and purveyor of science, it can be difficult to accept that sometimes the 'truth' is not what a patient needs," Lamas writes.
According to Lamas, in this situation, "[d]enial was [her] patient's only defense mechanism," and it was "cruel ... to try to take this defense from him in the final hours of his life."
Although Lamas prides herself on being gentle with patients and their families, even "difficult" ones, she was not gentle with this particular patient. In the essay, months later, Lamas writes that she isn't sure why she responded the way she did.
In part, she writes that her goal was to give her patient the information he needed so he could reach out to the ones he loved. However, Lamas acknowledges that she also responded to him with her own anger—in part because the patient might have survived if he had come in for treatment earlier.
"When I told him that he had only a few hours to live, I allowed my frustration to obscure the reality of his suffering," Lamas writes. "And I caused harm as a result."
Although it is a doctor's responsibility in most situations to tell their patients the truth and help them understand "even the most devastating realities," Lamas writes that, in this case, her response added to her patient's pain in his last few hours.
"I wish that I had done it differently," Lamas writes. "I could have paused and told him that yes, he was going to go home. I could have simply been there with him and said nothing at all. That small kindness might have done more for him than the truth." (Lamas, New York Times, 10/6)