death

[koma]

---

Members don't see this ad.

Is the word "death" taboo in the hospital? I haven't had those patient/doctor courses yet, but from shadowing etc, it seems the residents/attendings never ever talk to the patient about actually dying. It's very common to hear something like "I would like to discuss with you the end of life issues. Do you have a living will? Etc etc." Or "do you want us to take heroic measures if your heart stops beating?"

Is there actually a protocol on this, or is this just informal? Is talking about death with the patient discouraged?

One other thing that's disturbing is the ubiquitousness of TV's in the hospital. Whether the patient is in a coma, sleeping, or dying the TV is usually on. It's kind of disconcerting to walk into a room of someone in the agonal stage of death and see The Wheel of Fortune being broadcast. I wonder if there are studies on this.

 

[Winged Scapula]

There's no protocol but talking about death, especially with one who is expected to be dead in a fairly short period of time, is difficult. Difficult for the general population and difficult for health care workers, even physicians. Some of us are more comfortable with it than others - whether its experience, personality or what I don't know.

I do know however, that while I find it appropriate to discuss resuscitation/treatment issues with a patient, more in-depath discussions belong to the realm of Palliative Care. We've an excellent attending, a former Neurosurgeon, who runs our Pal Care service now and is fantastic with terminally ill patients and their families. I am more than willing to discuss details of the death process, but hedge on "how much time have I got, doc" discussions because you can never be sure. If someone wants a shoulder to cry on, if they feel close to their physician, that's great - but most of us have little training in the details of hospice, terminal care, etc. and find that experts in the field are better suited to such discussions.

I suspect if you haven't heard these discussions (when they might have been appropriate) its because the physician involved is not comfortable with such matters. Patients will often complain that their physician seemed to clear out of the room as soon as the information was offered; this is not something you can drop on someone when you have to be clinic in 10 minutes. At any rate, I don't know of anyone who discourages physicians (resident or otherwise) from talking with patients about death. Its part of the job and like most things, some of us are better at it than others.

As for the tv, I am unaware of any studies but the tvs are often on for the families or staff who might be in/out of the room. Obviously an agonal patient isn't too interested in whether or not he can buy a vowel.

 

[zepplinfan]

I don't want to sound crass or insensitive......but just a quick question:

Let's suppose as a doctor, you advise your patient that he/she may not have much longer to live (2-3 months). Now let's suppose the patient, based on this information, changes everything in their life (meaning: sells their house, goes on vacations, spends all their money, goes gambling and loses it all)......now suppose there was a misdiagnosis/lab error/miraculous recovery that no doctor could have predicted, can the patient sue the doctor cause he lost all his belongings due to the prognosis given by him/her? If so, I would think this is one reason not to make predictions on life expectancy.....am I right?

I just don't understand how in this sue-happy world, this wouldn't happen....maybe they won't succeed, but I see it happening.....do you?

 

[Mumpu]

Zep, this could happen if you told the patient "you have 3 months to live" and there may have been actual lawsuits about this. You would also deserve to get sued if you tell patient that.

Medicine is an extremely uncertain field. It is not appropriate to tell people they will die in 1 month unless you are planning to drive over to their house and give them a shot of KCl. It is appropriate to inform the patient that an average patient with the condition they have lives 2-3 months but that you cannot actually predict how long (or short!) they will last for.

 

[fab4fan]

As a hospice nurse, I see first-hand how uncomfortable some doctors are with talking to patients about death. I'm not saying that to sound judgemental; it's just a shame that it continues.

It's too bad that a rotation in palliative care isn't mandatory. I know it may not be the right specialty for a lot of doctors, but I think the experience would be just as beneficial as others. There are still docs out there who are afraid of aggressive sx mgmt; requiring a rotation in palliative care might be the first step in improving a physician's knowledge and comfort in caring for the terminally ill.

 

[Winged Scapula]

Mumpu is correct. You cannot tell a patient that HE has x amount of time to live - for the reasons stated above (there HAVE been lawsuits) and because medicine is an inexact science (to be cliched). You MAY tell the patient that the average patient with his disease survives X amount of time but that the range is generally X.

 

[Mumpu]

Fab4Fan, flogging is what turned me off from critical care medicine. I'm rotating through a private hospital now and many attendings are infuriatingly stubborn about keeping hopeless patients on 15 pressors for weeks. I think many schools still teach that to have a patient die is the ultimate failure for a physician which is terribly wrong.