Those days are fortunately long gone when a doctor’s job was also based on lies and suppression to shield the patient from the more unpleasant news. Today the truth is being told, it is often concrete and can be demanding to say and hear, and the doctor must prepare himself thoroughly before the serious conversation. It is therefore important to carefully consider what you want to say, when it is the right time and how you want to say it. The respect for the integrity of the individual patient therefore doesn’t encourage excessive guardedness concerning important information, however not unrestrained reconciling of expectation. But does the moment of truth really invite a direct hint as to the remaining lifetime?
The role of the doctor in the serious conversation is to avoid throwing the patient into an (even greater) crisis. And if the crisis happens after all, then at least follow it up with existential care. Care and introspection are important in the palliative context.
It is not unusual for patients with an incurable and life-threatening illness to recount their shocking experience when the doctor in connection with the final conversation at the hospital ward informed that there is no longer a treatment option, and at the end of the conversation a deadline in the most dramatic sense of the word: you have two months left. For the unfortunate, the doctor’s words and fateful tone of voice and the prospect that you are dying, the message’s inevitability will throw many already seriously ill patients into an existential crisis. At the final conversation all ties to the cancer specialists at the hospital are now severed, and for a while the patients will often feel at a loss and abandoned.
It is well known that every gloomy word from the mouth of the doctor is absorbed deep in the patient’s memory, is mulled over, turned over again and again. All terminally ill can exactly remember the time and the circumstances, the sounds and smells in the hospital, the intense atmosphere, when they receive their ‘death sentence’. The sad prognosis and the limited perspective can therefore develop into a total physical, psychological and social chaos that without a doubt impacts the quality of the life that the general practitioner and the subsequent palliative care and treatment try to maintain.
The spiritual and existential care starts at the latest, on the day when you are declared terminally ill. This information must be imparted gently – and in my view without a concrete deadline specifying the exact months. It is irresponsible and unethical towards the ill human being to hold out an authorized knowledge of the precise time there is left and indirectly establish a supposed death date, even though it is no doubt backed up by lots of data regarding the broader interpretation of cancer disease and prognosis. But the course of cancer varies from case to case and no statistics can exactly predict the patient’s future – two months left? Some patients will die before the deadline intimated by the doctor and they and their next-of-kin are often taken by surprise and possibly less prepared for the rapid development of the disease, while others die a long time after the intimation of the prediction and seem to be more composed about the course of their illness. They always express happiness to have lived a little longer and it is not unusual for a certain jovial satisfaction at having cheated both the doctor and death.
Patients and next-of-kin can of course during the final conversation insist on getting concrete information about the deadline. However, that will still just be a qualified guess about the many future variations within the statistical probabilities, a guess that doesn’t benefit anyone. Instead, the health professionals’ attention should first and foremost be aimed at the spiritual and existential dimension, a dimension that has never really gained a foothold at the hospitals.
It is important – and perhaps especially now when the spirit of the times makes many lives stressful – that we emphatically understand this period as a real and unpleasantly inevitable factor for the terminally ill and dying patient that is completely overwhelmed by this awful existential unstoppable condition: deadline.
