Menus Subscribe Search

Follow us


The Hardest Conversation: Talking About Death

• October 25, 2012 • 9:00 AM

A troubling number of terminally ill cancer patients don’t understand that chemotherapy won’t cure them. How can oncologists talk so that patients will listen?

There is a pandemic in the United States that no single-payer health care system, marvel of modern technology, nor homeopathic tincture can remedy. Medicare doesn’t cover it, and no blockbuster drug will treat it. Call it a “silent crisis.” Symptoms include, chiefly, poor communication between doctor and patient, false hope, and a willingness to move heaven and earth in the final months of life to find a cure where there is none. Prognosis is death without dignity.

That life is an ultimately fatal condition is inescapable—death is perhaps the only truly universal human experience. So why do we find it an impossible topic?

A study in this week’s New England Journal of Medicine illustrates how intractable the problem has become. According to lead author Jane C. Weeks of Harvard’s Dana-Farber Cancer Institute, 69 percent of lung cancer patients and 81 percent of colorectal cancer patients, “did not report understanding that chemotherapy was not at all likely to cure their cancer.”

The study population was comprised of 1,200 stage IV cancer patients—meaning the tumor had “metastasized” and spread throughout the body, and all but ensuring that the disease was terminal. As the authors note, the “survival benefit” of chemotherapy at this stage “is usually measured in weeks or months,” and comes with considerable toxic side-effects. They continue, “There is no uncertainty about whether chemotherapy offers any prospect of a cure”—which is to say, it most certainly does not—and yet many patients choose to undergo it anyway.

In the Weeks study, patients were interviewed at least four months after diagnosis, having already opted for chemotherapy. When the authors examined the responses, they found that education level didn’t correlate to a misplaced belief in chemo’s curative power. Race did, with blacks and Hispanics more likely to hold inaccurate expectations. “Paradoxically,” they write, “patients who reported higher scores for physician communication”—those one would expect to have the clearest understanding of their prognoses—“were also at higher risk for inaccurate expectations.”

The authors point to previous research showing that “patients with advanced cancer would accept toxic treatment for even a 1 percent chance of cure but would be unwilling to accept the same treatment for a substantial increase in life expectancy without cure.” Yet Weeks found that 96 percent of newly-diagnosed patients who discussed chemotherapy with their doctors chose to undergo it. How truly “informed” was their consent to treatment? Did oncologists not make clear the limited efficacy of chemo on stage IV cancer—or were patients simply not hearing it?

In an editorial that accompanies the study, oncologist Thomas Smith and molecular biologist Dan Longo observe that self-deception can be a “valuable personal coping tool.” But when it comes to end-of-life planning, self-deception can be costly, in terms of dollars, physical wellness, and emotional health. And patients aren’t to blame alone.

“It is not easy to tell patients that they are going to die,” Smith and Longo write, “and most of us choose not to do it. This may explain why two months before death, half of all patients with lung cancer have not heard any of their doctors use the word ‘hospice.’ ” If oncologists were to bring up palliative care sooner, and offer end-of-life counseling to families, patients would likely forgo chemo, live just as long, and incur a fraction of the hospital costs in the process. A full quarter of Medicare spending occurs in the last year of life, the authors note, which is no small part of why the system is going broke.

A breakthrough in communication would do far more to treat our fear-of-death epidemic than any revolution in technology or drugs. But it’s that fear that makes us human, and it’s not so easily shook.

Kevin Charles Redmon
Kevin Charles Redmon is a journalist and critic. He lives in Washington, D.C.

More From Kevin Charles Redmon

A weekly roundup of the best of Pacific Standard and PSmag.com, delivered straight to your inbox.

Recent Posts

October 24 • 8:00 AM

What Do Clowns Think of Clowns?

Three major players weigh in on the current state of the clown.


October 24 • 7:13 AM

There Is No Surge in Illegal Immigration

The overall rate of illegal immigration has actually decreased significantly in the last 10 years. The time is ripe for immigration reform.


October 24 • 6:15 AM

Politicians Really Aren’t Better Decision Makers

Politicians took part in a classic choice experiment but failed to do better than the rest of us.


October 24 • 5:00 AM

Why We Gossip: It’s Really All About Ourselves

New research from the Netherlands finds stories we hear about others help us determine how we’re doing.


October 24 • 2:00 AM

Congratulations, Your City Is Dying!

Don’t take population numbers at face value.


October 23 • 4:00 PM

Of Course Marijuana Addiction Exists

The polarized legalization debate leads to exaggerated claims and denials about pot’s potential harms. The truth lies somewhere in between.


October 23 • 2:00 PM

American Companies Are Getting Way Too Cozy With the National Security Agency

Newly released documents describe “contractual relationships” between the NSA and U.S. companies, as well as undercover operatives.


October 23 • 12:00 PM

The Man Who’s Quantifying New York City

Noah Davis talks to the proprietor of I Quant NY. His methodology: a little something called “addition.”


October 23 • 11:02 AM

Earliest High-Altitude Settlements Found in Peru

Discovery suggests humans adapted to high altitude faster than previously thought.


October 23 • 10:00 AM

The Psychology of Bribery and Corruption

An FBI agent offered up confidential information about a political operative’s enemy in exchange for cash—and they both got caught. What were they thinking?


October 23 • 8:00 AM

Ebola News Gives Me a Guilty Thrill. Am I Crazy?

What it means to feel a little excited about the prospect of a horrific event.


October 23 • 7:04 AM

Why Don’t Men Read Romance Novels?

A lot of men just don’t read fiction, and if they do, structural misogyny drives them away from the genre.


October 23 • 6:00 AM

Why Do Americans Pray?

It depends on how you ask.


October 23 • 4:00 AM

Musicians Are Better Multitaskers

New research from Canada finds trained musicians more efficiently switch from one mental task to another.


October 22 • 4:00 PM

The Last Thing the Women’s Movement Needs Is a Heroic Male Takeover

Is the United Nations’ #HeForShe campaign helping feminism?


October 22 • 2:00 PM

Turning Public Education Into Private Profits

Baker Mitchell is a politically connected North Carolina businessman who celebrates the power of the free market. Every year, millions of public education dollars flow through Mitchell’s chain of four non-profit charter schools to for-profit companies he controls.


October 22 • 12:00 PM

Will the End of a Tax Loophole Kill Off Irish Business and Force Google and Apple to Pay Up?

U.S. technology giants have constructed international offices in Dublin in order to take advantage of favorable tax policies that are now changing. But Ireland might have enough other draws to keep them there even when costs climb.


October 22 • 10:00 AM

Veterans in the Ivory Tower

Why there aren’t enough veterans at America’s top schools—and what some people are trying to do to change that.


October 22 • 8:00 AM

Our Language Prejudices Don’t Make No Sense

We should embrace the fact that there’s no single recipe for English. Making fun of people for replacing “ask” with “aks,” or for frequently using double negatives just makes you look like the unsophisticated one.


October 22 • 7:04 AM

My Politicians Are Better Looking Than Yours

A new study finds we judge the cover by the book—or at least the party.


October 22 • 6:00 AM

How We Form Our Routines

Whether it’s a morning cup of coffee or a glass of warm milk before bed, we all have our habitual processions. The way they become engrained, though, varies from person to person.


October 22 • 4:00 AM

For Preschoolers, Spite and Smarts Go Together

New research from Germany finds greater cognitive skills are associated with more spiteful behavior in children.


October 21 • 4:00 PM

Why the Number of Reported Sexual Offenses Is Skyrocketing at Occidental College

When you make it easier to report assault, people will come forward.


October 21 • 2:00 PM

Private Donors Are Supplying Spy Gear to Cops Across the Country Without Any Oversight

There’s little public scrutiny when private donors pay to give police controversial technology and weapons. Sometimes, companies are donors to the same foundations that purchase their products for police.


October 21 • 12:00 PM

How Clever Do You Think Your Dog Is?

Maybe as smart as a four-year-old child?


Follow us


Politicians Really Aren’t Better Decision Makers

Politicians took part in a classic choice experiment but failed to do better than the rest of us.

Earliest High-Altitude Settlements Found in Peru

Discovery suggests humans adapted to high altitude faster than previously thought.

My Politicians Are Better Looking Than Yours

A new study finds we judge the cover by the book—or at least the party.

That Cigarette Would Make a Great Water Filter

Clean out the ashtray, add some aluminum oxide, and you've (almost) got yourself a low-cost way to remove arsenic from drinking water.

Love and Hate in Israel and Palestine

Psychologists find that parties to a conflict think they're motivated by love while their enemies are motivated by hate.

The Big One

One company, Amazon, controls 67 percent of the e-book market in the United States—down from 90 percent five years ago. September/October 2014 new-big-one-5

Copyright © 2014 by Pacific Standard and The Miller-McCune Center for Research, Media, and Public Policy. All Rights Reserved.