As my colleague Melissa Healy noted Thursday, a British medical journal recently invited doctors who specialize in end-of-life care to debate whether patients should be told that they're terminally ill. Two London-based palliative care doctors argued in favor of disclosure, writing that it was "essential to decision-making" in addition to being the most ethical approach. The head of the palliative care section of the University of Virginia School of Medicine, meanwhile, asserted that telling patients they were terminal was "a failed model for medical decision making that creates more suffering than it relieves."
The latter piece, by Dr. Leslie J. Blackhall, is squirm-inducing stuff. Yet it highlights the struggle within the medical profession over how to deal with patients rapidly approaching their demise.
One factor in the struggle is the disproportionate amount of money spent on these patients. An enormous amount of resources are spent on people in their final few months on Earth, much of it on extraordinary efforts to forestall death that don't restore the patient's quality of life.
Yet Blackhall doesn't argue that patients should be kept in the dark about their prognosis in order to save money. Rather, she contends that telling people they are terminally ill invites them to make choices that may actually shorten their lives.
"Most adults die of chronic life-limiting illnesses such as cancer, end-stage heart and lung disease and complications of dementia," she writes. "In these illnesses, the choice between comfort and prolongation of life is usually a false one. Patients with dementia do not die faster without feeding tubes. Patients with advanced cancer do not die faster if they choose hospice or palliative care, and may in fact live longer, even though they are less likely to receive artificial life support."
She goes on to state: "Patients with advanced cancer and poor functional status do not need to know that they are terminally ill so that they can 'refuse' chemotherapy or cardiopulmonary resuscitation. In most cases they should not be given these treatments exactly because they are terminally ill."
This doctor-knows-best approach may be very appealing to people who look to their physician for wisdom, not just data. Those of us who grew up with "Marcus Welby, M.D." or "ER" think of doctors as relentless advocates for the sick, people who put their patients' interests first. That image is sustained by reports such as the one Thursday in the New York Times about leukemia specialists publicly appealing to drug companies to slash the cost of certain lifesaving drugs, even at the risk of losing those companies' support for their research.
Nevertheless, Blackhall's position runs counter to what seems to be a full-court press within the industry to get patients to fill out "advance directives" on end-of-life care. The whole point of those directives is to have individuals, not doctors, make decisions about how far to go to try to forestall death.
Considering how much outrage opponents of the 2010 healthcare law have drummed up over mythical government "death panels," my guess is that most consumers would be apoplectic about doctors who withheld a bad prognosis from their patients. But how do you feel? Take our non-peer-reviewed and wholly unscientific poll, leave a comment, or do both.
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