How Facing Death Changed the Way I Treat Patients

Fear and anxiety are powerful emotions, especially when a patient faces an unsettling medical diagnosis.

As a healthcare provider, I see it every day. But as a cancer clinician in particular, I am extra mindful of the thoughts and emotions that wash over newly-diagnosed patients.

One of the keys to being a good physician is to have an understanding of what your patients are going through, especially what they are thinking and not saying. I find myself — with each passing year and each new patient — giving pause to reflect on how I’m communicating, how I’m heard and if I’m understood. More than how I feel, it matters how my patients feel.

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I am convinced that uncertainty makes all of these emotions worse. That is why getting access to see a doctor rapidly is so important. Most patients have reduced anxiety if a treatment plan is discussed, defined, and agreed upon. Every day is another step in the plan. A routine develops. There may be variations to the routine, and clinical issues may necessitate a change in plan, but a treatment plan dampens the level of anxiety that patients experience.

Any empathetic person can understand the emotions that arise when faced with a cancer diagnosis. But can you really understand, if you have never been seriously ill?

I thought I could when I first became an oncologist. Looking patients in the eye. Getting to know them, their families, their concerns, their hopes – it wasn’t hard to appreciate the enormity of what cancer does to people. But I did not really understand how illness can warp your thinking and consume your thoughts until I became seriously ill about 20 years ago.

The details are not important. My heart was a mess. I was in an ICU on an intra-aortic balloon pump for quite a while, awaiting open heart surgery. I was a physician, and I knew what the prognosis was for younger patients with a medical illness that required a pump. My mortality was staring me in the face. Fortunately, I had a good outcome. But my life was forever changed.

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My life as a patient

In the weeks and months following my medical crisis, I thought about dying a lot — and what life for my family would be after I died. Even though I had treated many cancer patients who did not survive, the reality and inevitability of my own death for the first time became front and center in my mind. I thought about my illness and mortality every day, multiple times a day. In some ways it was liberating as I made choices on a different timeline with my new sense of prioritization. We splurged on family vacations. I thought about what added value more than my previous duty-bound tasks. But the issue of death, my death, was there all the time.

Over the years, I think about it less. But it remains, lurking. Probably forever.

So how is this of any use for all of you who care for cancer patients? Let me share some lessons from my own experience that now shape my patient relationships:

• Be mindful of the minority. A great many patients, fortunately, beat back cancer and return to their life’s path. However, a minority of patients in your cancer center are fully aware that their death is right around the corner. They and their families are following their path as best they can. Treat them with respect, consideration and empathy. Consider that loud celebrations when another patient completes chemotherapy might be especially painful for them. Think about the patients who can’t help but think of their mortality, and keep the celebrations private. Walk in the shoes of those who will not be with us next year.
• Forge a personal connection. As the doctor, it’s vital that you communicate fundamental facts about their disease, prognosis and treatment. They can receive and process this vital medical information much more easily if you try to connect with each patient on some sort of personal level. Take the time to do so. Talk about their work, school, exercise…something, anything. Be human. Do whatever it takes to remove that glaze from their eyes and to focus on all the things in their life that are continuing.
• Humor helps. When building that personal bond, I generally try humor. If you can connect on that level, then dealing with these serious subjects gets a bit easier. When their guard is down, and they relax a bit, they will open up about undiscussed issues. And those frequently are the scariest topics of all.
• Acknowledge the challenges. It’s ok to say that the situation sucks if it does. Sometimes patients want to cut the cord with you prematurely after their primary treatment, given the reality of their fear and the full realization of their own mortality. If so, it’s a good idea to talk it out with them, and consider a compromise about scheduled follow-ups.

Obviously an entire literature exists about the long term psychological ramifications of a cancer diagnosis. Even if you think you “get it,” consider the possibility that there are more things to understand. The issue of their own mortality does not go away — even when you say the word “cure.”

It lingers for a very long time. Just ask them.