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

August 22 • 4:00 PM

The Invention of the Illegal Immigrant

It’s only fairly recently that we started to use the term that’s so popular right now.



August 22 • 2:00 PM

What Can U.S. Health Care Learn From the Ebola Outbreak?

A conversation with Jeanine Thomas, patient advocate, active member of ProPublica’s Patient Harm Facebook Community, and founder and president of the MRSA Survivors Network.


August 22 • 1:22 PM

Two Executions and the Unity of Mourning

The recent deaths of Michael Brown and James Foley, while worlds apart, are both emblematic of the necessity for all of us to fight to uphold the sanctity of human dignity and its enduring story.


August 22 • 10:00 AM

Turbo Paul: Art Thief Turned Art Crime Ombudsman

There’s art theft, there’s law enforcement, and, somewhere in between, there’s Turbo Paul.


August 22 • 8:00 AM

When Climate Change Denial Refutes Itself

The world is warming—and record-cold winters are just another symptom.


August 22 • 6:17 AM

The Impossibility of the Night Shift

Many night workers get “shift-work sleep disorder.” And no one knows how to treat it.


August 22 • 6:00 AM

Long Live Short Novels

Christopher Beha’s Arts & Entertainments comes in at less than 300 pages long, which—along with a plot centered on a sex-tape scandal—makes it a uniquely efficient pleasure.


August 22 • 4:00 AM

Why ‘Nature Versus Nurture’ Often Doesn’t Matter

Sometimes it just doesn’t make any sense to try to separate the social and the biological.


August 21 • 4:00 PM

Julie Chen Explains Why She Underwent Westernizing Surgery

The CBS news anchor and television personality’s story proves that cosmetic surgeries aren’t always vanity projects, even if they’re usually portrayed that way.


August 21 • 2:37 PM

How the Brains of Risk-Taking Teens Work

There’s heightened functional connectivity between the brain’s emotion regulator and reason center, according to a recent neuroscience paper.


August 21 • 2:00 PM

Cracking Down on the Use of Restraints in Schools

Federal investigators found that children at two Virginia schools were being regularly pinned down or isolated and that their education was suffering as a result.


August 21 • 12:00 PM

What Makes You So Smart, School Principal?

Noah Davis talks to Evan Glazer about why kids aren’t getting smarter and what his school’s doing in order to change that.



August 21 • 10:00 AM

Why My Neighbors Still Use Dial-Up Internet

It’s not because they want to. It’s because they have no other choice.


August 21 • 8:15 AM

When Mothers Sing, Premature Babies Thrive

Moms willing to serenade pre-term infants help their babies—and themselves.


August 21 • 8:00 AM

To Fight the Obesity Epidemic Americans Will Have to First Recognize That They’re Obese

There is a void in the medical community’s understanding of how families see themselves and understand their weight.


August 21 • 6:33 AM

One Toxic Boss Can Poison the Whole Workplace

Office leaders who bully even just one member of their team harm everyone.


August 21 • 6:00 AM

The Fox News Effect

Whatever you think of its approach, Fox News has created a more conservative Congress and a more polarized electorate, according to a series of recent studies.


August 21 • 4:00 AM

Do Children Help Care for the Family Pet?

Or does mom do it all?


August 20 • 4:00 PM

Why Can’t Conservatives See the Benefits of Affordable Child Care?

Private programs might do a better job of watching our kids than state-run programs, but they’re not accessible to everyone.


August 20 • 2:00 PM

Oil and Gas Companies Are Illegally Using Diesel Fuel in Hundreds of Fracking Operations

An analysis by an environmental group finds hundreds of cases in which drillers used diesel fuel without obtaining permits and sometimes altered records disclosing they had done so.


August 20 • 12:00 PM

The Mystery of Britain’s Alien Big Cats

In a nation where the biggest carnivorous predator is a badger, why are there so many reported sightings of large cats?


August 20 • 10:00 AM

Death Row in Arizona: Where Human Experimentation Is the Rule, Not the Exception

Recent reports show that chemical roulette is the state’s M.O.


August 20 • 9:51 AM

Diversity Is in the Eye of the Beholder

Perception of group diversity depends on the race of the observer and the extent to which they worry about discrimination.


Follow us


The Impossibility of the Night Shift

Many night workers get “shift-work sleep disorder.” And no one knows how to treat it.

How the Brains of Risk-Taking Teens Work

There's heightened functional connectivity between the brain's emotion regulator and reason center, according to a recent neuroscience paper.

When Mothers Sing, Premature Babies Thrive

Moms willing to serenade pre-term infants help their babies—and themselves.

One Toxic Boss Can Poison the Whole Workplace

Office leaders who bully even just one member of their team harm everyone.

Diversity Is in the Eye of the Beholder

Perception of group diversity depends on the race of the observer and the extent to which they worry about discrimination.

The Big One

One in two full-time American fast-food workers' families are enrolled in public assistance programs, at a cost of $7 billion per year. July/August 2014 fast-food-big-one
Subscribe Now

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