“Am I going to die, Dr?”

“Death is not the opposite of life, but a part of it.” Haruki Murakami

“Am I going to die, Dr. Goh?” Mrs. O* asked me when she was admitted for an infected diabetic wound on her right foot. She had been on dialysis for the past 3 years after her kidneys failed due to diabetic complications. To make matters worse, she had been admitted multiple times before for upper gastrointestinal bleeding and hepatic encephalopathy (coma) due to cirrhosis of the liver. Years ago, she was diagnosed with a hepatitis B infection.

Predicting the outcome for a patient with multiple medical problems is a difficult task. Prognosis, like most aspects of clinical medicine, is both an art and a science that can vary widely even among patients with the same medical condition. Of the three pillars of modern clinical medicine, diagnosis, treatment, and prognosis, the first two are always overemphasized in medical education. However, the third pillar of medicine – prognosis – is largely undervalued in daily clinical practice.

Normally, doctors rarely give a definite answer about a patient’s prognosis. However, when I started her on dialysis three years ago, I knew that Mrs O*’s annual mortality rate would be over 20% (a combination of kidney failure and Child C liver cirrhosis), and I openly told the husband that I hoped to give her two to three more years with a good quality of life.

Prognosis in clinical medicine

Prognosis, the likelihood of a patient achieving a certain outcome over a period of time, is a key factor in the provision of high-quality, patient-centred care. Most patients and their family members hope that this aspect of the illness can be conveyed to them, unfortunately most clinicians cite fear of taking away patients’ hope or disrupting the patient-clinician relationship as key barriers to prognostic disclosure. Therefore it is not surprising that, in a study of more than 1100 patients with incurable metastatic lung or colorectal cancer, 74% thought that the intent of chemotherapy was cure.

The prognosis is inevitably a prediction of death. This is a troubling issue for both patients and doctors. However, I always make it a point to educate my terminally ill patients (almost all of my dialysis patients) about their prognosis. I find it very disheartening to see people at the end of their lives being given what I call “futile treatment” that we all know would never work.

Over-treatment in modern medicine

Because most patients or their immediate families do not understand prognosis well, doctors occasionally find it difficult to meet their expectations, and these patients are usually overtreated. In Asian culture, people tend to feel guilty about giving conservative treatment to their dying family members. Therefore, it is common for terminally ill patients with a poor prognosis to be cut open, fitted with tubes, hooked up to machines and anaesthetized with drugs just to prolong their misery.

All this happens because some patients and their family members do not understand the disease properly, have unrealistic expectations or have been poorly informed by their doctors about their long-term outcome.

Research shows that most Americans do not die well, meaning they do not die the way they want to – at home, surrounded by the people they love. According to Medicare data, only one-third of patients die this way. More than 50 per cent spend their last days in hospitals, often in intensive care units, hooked up to machines and feeding tubes, or in nursing homes.

Doctors die in a different way

Joel S. Weissman of the Centre for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts, associate director and chief scientific officer of CSPH and associate professor of health policy at Harvard Medical School, found that compared to the general population, physicians were less likely to die in a hospital (27.9 per cent versus 32 per cent), and in the last six months of life, they were less likely to undergo surgery (25.1 per cent versus 27.4 per cent) and less likely to be admitted to intensive care (25.8 per cent versus 27.6 per cent).

Why do doctors die in a different way? We know enough about death and we know what people fear most: dying in agony and ending up with several broken ribs, knowing that cardiopulmonary resuscitation should not even be performed. And of course, dying alone, without immediate family members nearby.

Doctors do not over-therapy themselves. I hope that when my time comes, I can find a way to die peacefully at home, and that the pain can be managed on an outpatient basis by the hospice team.

Conclusion

Yes, I told Mrs O* that she was dying, but the least I could do was to help her die in a pain-free and dignified way. I respect my patient’s final decision and also hope that she was able to decide for herself what kind of treatment she wanted in her last moments. I have no intention of over- or under-treating my patients, but I always try my best to inform them of their prognosis.