Menus Subscribe Search

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

July 25 • 4:00 PM

Flying Blind: The View From 30,000 Feet Puts Everything in Perspective

Next time you find yourself in an airplane, consider keeping your phone turned off and the window open.


July 25 • 2:00 PM

Trophy Scarves: Race, Gender, and the Woman-as-Prop Trope

Social inequality unapologetically laid bare.


July 25 • 1:51 PM

Confusing Population Change With Migration

A lot of population change is baked into a region from migration that happened decades ago.


July 25 • 1:37 PM

Do Not Tell Your Kids That Eating Vegetables Will Make Them Stronger

Instead, hand them over in silence. Or, market them as the most delicious snack known to mankind.



July 25 • 11:07 AM

The West’s Groundwater Is Being Sucked Dry

Scientists were stunned to discover just how much groundwater has been lost from beneath the Colorado River over the past 10 years.


July 25 • 10:00 AM

Shelf Help: New Book Reviews in 100 Words or Less

What you need to know about Bad Feminist, XL Love, and The Birth of Korean Cool.



July 25 • 8:00 AM

The Consequences of Curing Childhood Cancer

The majority of American children with cancer will be cured, but it may leave them unable to have children of their own. Should preserving fertility in cancer survivors be a research priority?


July 25 • 6:00 AM

Men Find Caring, Understanding Responses Sexy. Women, Not So Much

For women looking to attract a man, there are advantages to being a caring conversationalist. But new research finds it doesn’t work the other way around.


July 25 • 4:00 AM

Arizona’s Double-Talk on Execution and Torture

The state is certain that Joseph Wood’s death was totally constitutional. But they’re looking into it.


July 24 • 4:00 PM

Overweight Americans Have the Lowest Risk of Premature Death

Why do we use the term “normal weight” when talking about BMI? What’s presented as normal certainly isn’t the norm, and it may not even be what’s most healthy.


July 24 • 2:00 PM

California’s Lax Policing of the Fracking Industry Has Put the Drought-Stricken State in a Terrible Situation

The state’s drought has forced farmers to rely on groundwater, even as aquifers have been intentionally polluted due to exemptions for the oil industry.


July 24 • 12:00 PM

What’s in a Name? The Problem With Washington’s Football Team

A senior advisor to the National Congress of American Indians once threw an embarrassing themed party that involved headdresses. He regrets that costume now, but knows his experience is one many others can relate to.


July 24 • 11:00 AM

How Wildlife Declines Are Leading to Slavery and Terrorism

As wildlife numbers dwindle, wildlife crimes are rising—and that’s fueling a raft of heinous crimes committed against humans.


July 24 • 10:58 AM

How the Supremes Pick Their Cases—and Why Obamacare Is Safe for Now

The opponents of Obamacare who went one for two in circuit court rulings earlier this week are unlikely to see their cases reach the Supreme Court.



July 24 • 9:48 AM

The People Who Are Scared of Dogs

While more people fear snakes or spiders, with dogs everywhere, cynophobia makes everyday public life a constant challenge.


July 24 • 8:00 AM

Newton’s Needle: On Scientific Self-Experimentation

It is all too easy to treat science as a platform that allows the observer to hover over the messiness of life, unobserved and untouched. But by remembering the role of the body in science, perhaps we humanize it as well.


July 24 • 6:00 AM

Commercializing the Counterculture: How the Summer Music Festival Went Mainstream

With painted Volkswagen buses, talk of “free love,” and other reminders of the Woodstock era replaced by advertising and corporate sponsorships, hippie culture may be dying, but a new subculture—a sort of purgatory between hipster and hippie—is on the rise.


July 24 • 5:00 AM

In Praise of Our Short Attention Spans

Maybe there’s a good reason why it seems like there’s been a decline in our our ability to concentrate for a prolonged period of time.


July 24 • 4:00 AM

How Stereotypes Take Shape

New research from Scotland finds they’re an unfortunate product of the way we process and share information.


July 23 • 4:00 PM

Who Doesn’t Like Atheists?

The Pew Research Center asked Americans of varying religious affiliations how they felt about each other.


July 23 • 2:00 PM

We Need to Start Tracking Patient Harm and Medical Mistakes Now

Top patient-safety experts call on Congress to step in and, among other steps, give the Centers for Disease Control and Prevention wider responsibility for measuring medical mistakes.


July 23 • 12:19 PM

How a CEO’s Fiery Battle Speeches Can Shape Ethical Behavior

CEO war speech might inspire ethical decisions internally and unethical ones among competing companies.


Follow us


Subscribe Now

Do Not Tell Your Kids That Eating Vegetables Will Make Them Stronger

Instead, hand them over in silence. Or, market them as the most delicious snack known to mankind.

The West’s Groundwater Is Being Sucked Dry

Scientists were stunned to discover just how much groundwater has been lost from beneath the Colorado River over the past 10 years.

How Wildlife Declines Are Leading to Slavery and Terrorism

As wildlife numbers dwindle, wildlife crimes are rising—and that's fueling a raft of heinous crimes committed against humans.

How a CEO’s Fiery Battle Speeches Can Shape Ethical Behavior

CEO war speech might inspire ethical decisions internally and unethical ones among competing companies.

Modern Technology Still Doesn’t Protect Americans From Deadly Landslides

No landslide monitoring or warning systems are being used to protect vulnerable communities.

The Big One

Today, the United States produces less than two percent of the clothing purchased by Americans. In 1990, it produced nearly 50 percent. July/August 2014

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