Articles

Should a Doctor Tell You If You're Going To Die?

No doctor can say definitely that an illness must be fatal but often he recognizes the signs that point to impending death, When he sees these signs

FRED BODSWORTH September 1 1951
Articles

Should a Doctor Tell You If You're Going To Die?

No doctor can say definitely that an illness must be fatal but often he recognizes the signs that point to impending death, When he sees these signs

FRED BODSWORTH September 1 1951

Should a Doctor Tell You If You're Going To Die?

Articles

No doctor can say definitely that an illness must be fatal but often he recognizes the signs that point to impending death, When he sees these signs

FRED BODSWORTH

WHEN A DOCTOR finds out that a patient is fatally ill, and believes the patient has only a few months or a year or two to live, should he tell him the truth about his

illness, a white lie or nothing at all? This is one of the most difficult problems doctors face.

Fear of death is instinctive. When someone incurably ill asks “Am I going to die?” the most scrupulously honest friend will probably answer “Of course not.” The lie is condoned by nearly everybody as the only kind and considerate answer possible. But is it?

There is no universally accepted answer. Medical schools rarely if ever mention it. The Canadian Medical Association’s code of ethics, which lays down policy for numerous related problems, says nothing about this problem. Every doctor is left to work out his own answer. And their opinions vary.

Failure to tell a person of impending death often means that needless legal and financial worries are left with survivors. Furthermore, the doctor who tells a white lie and insists that a patient is not dangerously ill, when he knows the patient is Year death, is undermining his professional reputation, for the family will probably accuse him of incompetence when death does occur.

On the other hand, the news that a person lias entered "his final year of life may crearte a mental break-up, deprive him of his will to live and shorten that life still inore. In some cases it has caused depressed patients to commit suicide. It means a longdrawn-out period of grief for members of the family who could be spared that grief, at least until near the end.

I asked a number of doctors and ministers if they thought a fatally ill patient should be told the truth. A few gave an unqualified “No.” But most felt there could be no final “Yes” or “No.” To tell or not to tell must depend on the circumstances and the patient’s personality, they said. Some patients could not be told they were near death, but the majority of patients could -and should—be told.

A few years ago a husky young Toronto man walked into a doctor’s office and asked for something to ease his severe headaches. Aspirins had helped at first, he said, but the headaches were becoming more severe and lasted longer. He had noticed too a couple of peculiar mental lapses. Once his vision blurred, then two or three seconds later it was normal.

The doctor recognized that a brain tumor could produce these symptoms. He examined the young man’s eyes. There was some evidence of swelling of the optic nerve-head, a condition that often accompanies a brain tumor. Without saying anything to alarm the patient he arranged for an examination by a brain specialist and a hospital appointment for an electro-encephalograph test. The electro-encephalograph, which detects and

records electrical impulses from the brain, showed a definite distortion of brain waves in the right forehead area. The specialist completed his examination, then talked to the patient’s doctor.

“It’s a tumor and it’s too big to touch,” he said. “You’d better tell him the headaches will come and go, maybe disappear at times for a week or month, but that it’s almost certain to be fatal in from six months to a year and a half.”

The doctor had been out of medical school only three years. He had never had the distressing task of telling a patient he was going to die. Except for his periodic headaches the young man was in good spirits, doing well as a real-estate salesman, and he had no suspicion of the critical nature of his case.

“I knew he should be told, but I finally had to admit that J couldn’t do it,” the doctor related recently. “I kept him provided with drugs that controlled the headaches and I never did tell him his condition was incurable. The next thing I knew he was married and his wife was pregnant and coming to me for prenatal care. They were buying a house and a car. He lived for two years and when he died he left a young widow with a small boy and debts she couldn’t possibly take care of. The plight of that young widow was entirely my fault.”

But overshadowing all ramifications of this perplexing problem is the inescapable fact that no doctor, regardless of his experience and skill, can say definitely that a specific condition must be fatal. Medical research and discovery are constantly providing new cures. Diseases such as endocarditis (inflammation of the lining of the heart), which ten years ago were regarded as inevitably fatal, are now curabte in many cases.

Dr. William J. Clark, a Toronto physician who has been practicing for fifty-three years, told me: “I have seen or heard of hundreds of cases that ‘absolutely can’t get better,’ but just the same they did. There is always that one-in-a-hundred chance that even the most hopeless case will somehow pull through. If you tell that man he’s going to die you may rob him of his will to live and deprive him of that last chance he has of getting better.” “You often hear statements such as ‘The doctor has given him six months to live, ’ ” said Dr. Arthur D. Kelly, assistant; secretary of the Canadian Medical Association. “I doubt if they are often accurate, for a doctor can never safely be as specific as that. What the doctor probably said was something like this: ‘Most cases that have reached the acute stage of yours prove fata'l in six months or so and T would advise you to prepare your affairs. But occasionally a case like yours progresses slowly and it is possible you might live for several years.’ ”

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Errors in diagnosis, and cures in cases where doctors felt there was no hope, are extremely rare, yet they do occur often enough to make most doctors refrain from an

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unqualified prognosis of death. “1 never tell a patient he is going to die,” a family doctor told me, “but I some times warn patients their chances of living more than a year or two are very slim.”

Dr. W. J. McCormick, a Toronto specialist in nutrition and neurology, warned that nature occasionally fools the doctor who is sure he has an incurable patient. “I once had a man with pneumonia,” he said. “His pulse was rapid, his lungs were filling with fluid and the temperature was high. I called in another specialist and he agreed wth me there was nothing that could be done. He even asked me to arrange for a post-mortem because it was an unusual case and he was anxious to check other aspects of the patient’s condition. I told the wife that her husband was not likely to live until morning. Then I tried a radical treatment —a heavy dose of a sulpha drug with high dosage of vitamin C to counteract the sulpha’s toxic effect. By morning he was rapidly improving and in twenty-four hours he was completely normal.”

The best of physicians occasionally make an error in diagnosis, as a recent case in England illustrated. In 1942, James F. Whiteford, an American engineer employed in London by a U. S. firm, went to one of the city’s best-known surgeons with a bladder complaint. The surgeon, Dr. J. B. Hunter, was confident he could correct the condition, and operated. But instead of finding the condition he exj pected Hunter discovered what he j believed to be a large inoperable j cancer of the bladder. He told Whitej ford that unless there was an unusually retarded development the cancer would cause death in a matter of months. He ■ advised him to quit his job, return to the U. S., see his family and set his | estate in order. The engineer followed j the surgeon’s advice.

Six months later a Dr. Barringer in New York, using an instrument the j London surgeon did not have access j to, took a scraping from the bladder wall and diagnosed the “cancer” as a non-malignant tumor. He removed j the tumor and after a long convalescence Whiteford was in perfect health. The engineer returned to hjs position in London and sued Hunter for malj practice. He was awarded twenty i thousand dollars for the economic inconvenience and mental anguish the I wrong diagnosis had caused. Hunter j appealed to a higher court, which ruled that the inaccurate diagnosis was a mistake any doctor might reasonably make; the suit for damages was dismissed.

Such rare mistakes make doctors cautious in forecasting death, but they are so rare that the problem of “to tell or not to tell” remains unaffected.

Most doctors and ministers I talked to said they had known cases in which it would have been unwise to tell patients the truth about an incurable illness. But only a few felt the truth should be withheld in all cases, regardless of circumstances, though most agreed that no specific time limit should be set on the patient’s remaining days.

One doctor was definite about keeping the prospect of death a secret. “There is no problem to it at all,” he said, “when you consider that a doctor’s only mission is to cure, improve or at least prolong life. No patient should be told he is going to die. It would only aggravate the disease, create a certain amount of shock and surely quicken the progress of the illness. I

wouldn’t even tell a wife or husband or any member of the family living with the patient, for a cheerful attitude on their part will benefit the patient and help prolong life. But to protect my own professional standing I have told the truth to adult sons when 1 felt they were capable of keeping the knowledge to themselves. Often an adult son can see that all legal and financial matters are in order without creating concern on the part of the patient and other members of the family.”

But the secret of what to tell and whom to tell about a patient’s condition

lies in how well the doctor knows his patient. In many cases of cancer, leukemia, brain tumor or Addison’s disease often incurable and almost always fatal-—the patient is told the truth, or made to realize the truth by careful hints. But first the doctor has determined by careful study whether the person is emotionally stable and can face the fact of death philosophically and calmly.

“I sometimes ask a patient whom I consider incurable to come back several times over a period of weeks,” one doctor said. “There is usually nothing

I can do for him, but it gives me the opportunity to test his emotional stability and determine whether he can face the truth. If he is a man with business responsibilities or with a wife and family dependent on him it is usually advisable to tell him his life expectancy is limited. He may have no idea of the seriousness of his condition, and it is surprising how careless many otherwise efficient businessmen are in providing for dependents.”

But neurotic, excitable people cannot be told they are going to die without risk of breaking them up mentally,

aggravating their disease and filling their last days with panic and misery. Doctors and ministers told me that such people are not common. When they are encountered the doctor, with the aid of relatives, usually strives to hide the truth.

Another group from whom the truth is usually withheld are elderly persons with grown-up families and no business attachments. There is no need to tell them they are going to die. It will serve no purpose and might do harm. Yet they are usually the ones who can face death with the most composure.

“You can always identify the people who are better off not told that they have a fatal illness,” a young doctor told me. “They never face squarely up to reality, refuse to admit they are seriously ill and have frequently postponed visiting a doctor because they are afraid to find out what is wrong with them. They are always grasping at straws, hoping some magic cure will make them better. They are the people who keep medical quacks in business.”

A fairly common patient of this type is the woman with cancer of the breast. A doctor described a typical case. When the woman first visited him the lump in her breast was already large and he quickly diagnosed it as a cancer. Six months earlier the cancer could have been removed and a complete cure would have resulted, but now secondary cancers were forming in the lymph glands of the armpits and the lungs. There was no hope. Should he tell her the truth?

He asked her when she had first noticed the lump, knowing what the story would be. She had first noticed a tiny hard lump almost a year before. She immediately feared cancer, but clung to the hope it wasn’t. The lump grew larger. Two or three months later she told her husband and he made an appointment for her with the doctor. But she couldn’t face a possible adverse verdict and telephoned to break the appointment.

Now, six months too late, she was in his office. Her hands trembling, she asked: “It isn’t cancer, is it?” Obviously she was not a patient to be told the truth. The doctor shook his head. “Just a non-malignant tumor,” he told her. “We’ll wait a few months and maybe remove it then.” Five months later, still believing her condition was not serious, she died of cancer.

Several doctors told me, however, there were circumstances in which even this type of patient should be forced to face the truth for the sake of dependents.

“At one time I would not have agreed with this, but I do now,” one doctor said. “Several years ago I had two cases, close together, which made up my mind. Both were young men with small families. The first husband had leukemia. He was immature in many respects, highly emotional, and I knew he had gone to pieces so badly at his mother’s death that he couldn’t even attend the funeral. I knew he had only about a year to live, but I didn’t tell either him or his wife. Afterward I learned that he had surrendered life insurance to buy a car and he left his wife without a cent.

“Not long afterward I had another case of a young man with two children. He had nephritis, his kidneys were seriously damaged by an infection and at first I thought he would live. But he failed to respond to treatment and it became apparent his disease was going to be fatal. Emotionally, he was unstable—a case in which a doctor would not normally tell the patient he had little chance of surviving. I knew he would take it badly, but I felt it wisest to protect the wife and children. So I broke the news in stages and

gradually made him realize the truth. For a week or two he couldn’t sleep, but he finally pulled himself together and faced it like a man. He had a small insurance agency and he spent the last six months of his life training his wife so she could carry on. When he died she stepped into his business and she’s been making a good living for her children ever since.”

Dr. Kelly, of the Canadian Medical Association, told me that the will to live is vitally important in treating acute illnesses such as pneumonia. Most doctors, he said, refrain from telling the truth in these cases, no matter how hopeless the case may appear. “When a pneumonia patient gives up mentally he has lost half the battle,” Kelly said. “He needs all his resources. He needs to be bolstered psychologically and encouraged to hope and fight.

The average stable adult who is seriously ill, however, wants to know if it is likely to be fatal and usually takes the news calmly, often thanking his doctor for giving him the facts.

Canon C. A. Moulton, of St. Simon’s Anglican Church in Toronto, recently told me about a parishioner who he knew was slowly dying. “I was young then and thought the thing to do was to encourage him to look forward to life. After a couple of months I found he knew he was going to die and had been carefully winding up his business affairs and instructing his family on what would have to be done after his death. He changed all my ideas on the subject.

“I have realized since that it is often mistaken kindness to try to hide impending death from an incurably ill person. Many want to face facts, no matter what those facts are. Many men have built successful business careers by foreseeing and preparing for misfortunes, as well as by taking advantage of good fortune. Spiritually we refuse to regard death as a misfortune, but in a business sense it probably can be regarded as such. To deprive the average man of the opportunity of preparing for this last great misfortune of his career is unjust and usually unnecessary. But a minister must never try to be a doctor. He must always learn from the doctor first whether the patient can be told the truth without causing harm.”

Doctors emphasized legal and financial considerations as the main reason for telling the truth to a patient whose life expectancy is limited. Several ministers suggested another reason: Many people have goals in life they are anxious to achieve, goals which range from a scientist’s research project to a midwest farmer’s vow to see Niagara Falls before he dies. The man who knows he has only a year or two to live can frequently plan his last months and do those things he has always planned to do.

Man runs the full gamut from hysteria to heroism when he faces the fact of death. The hysterical person is rare, for he is usually identified in advance and the truth kept from him. On the heroic side are to be found some of humanity’s greatest stories.

One man on his deathbed handed a minister twelve envelopes addressed to his wife, with instructions to give her

one each month for a year after he was gone. Not until the minister delivered the last envelope and the wife passed the letter back to him to read did he realize the selflessness with which that husband had faced death. The last letter said, in part: “You will have

grieved long enough, my darling. Now it is time to put aside grief. You are not meant to live alone. If you have not already found someone, from now on open vour heart. Only through loving and being loved are you complete. Only your lasting grief could now make me sad.”

Another case was revealed when a four-year-old child was brought to a nursery school by her twelve-year-old sister. The teacher chatted with the newcomer and told her she liked her blue dress. “My mummy and my sister made it,” the four-vear-old said proudly.

Later the teacher mentioned the sisters to a neighboring woman. “I never saw such well-trained children,” she commented.

“She has two sisters and a brother, all under twelve,” the neighbor said. “The older girls are responsible for the small

one. Their mother is carefully training all of them to care for themselves, the house, and do the shopping and cooking, so that they and the father will always have a smoothly run home.”

The teacher looked puzzled. “Why?” she asked. “Is the mother going away?”

“Yes,” the neighbor replied. “She’s known for a year that she is dying of cancer.”

Should doctors tell you if you are going to die? Most doctors claim that only in a few cases does the answer need to be “No.” if

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