"Will I Die, Doctor?" — Dr. Goh Heong Keong
"Will I die, Dr. Goh?"
This was the poignant question posed by Mrs. O when she was admitted due to an infected diabetic ulcer on her right foot. For the past three years, she had been undergoing dialysis following the failure of her kidneys, a dire consequence of complications stemming from diabetes.
As if her situation weren't dire enough, Mrs. O had a history of multiple hospitalizations for serious issues, including upper gastrointestinal bleeding and hepatic encephalopathy—a state of coma brought on by cirrhosis of the liver. Years earlier, she had also been diagnosed with a hepatitis B infection, further complicating her health profile.
Assessing the prognosis for a patient grappling with numerous medical conditions is a formidable challenge. The journey of predicting outcomes in medicine blends both art and science, often leading to significant variations even among patients experiencing similar ailments.
In the realm of modern clinical medicine, there are three fundamental pillars: diagnosis, treatment, and prognosis. While medical education tends to prioritize the first two, the vital third pillar—prognosis—is frequently overlooked in everyday practice.
Typically, healthcare providers hesitate to provide definitive answers regarding a patient's prognosis. However, during Mrs. O's initial dialysis session three years prior, I understood that her annual mortality rate would exceed 20 percent, given her combination of kidney failure and advanced liver cirrhosis (Child C). I candidly shared with her husband my hope of granting her an additional two to three years of life, filled with quality moments.
Understanding Prognosis in Clinical Medicine
Prognosis refers to the likelihood that a patient will achieve specific outcomes over time, serving as a crucial element in delivering patient-centered care.
While many patients and their families yearn for clarity on this aspect of their medical journey, many clinicians cite fears of diminishing hope or damaging the rapport between patient and doctor as barriers to open prognostic conversations.
As a result, it's not surprising that in a study involving over 1,100 patients diagnosed with incurable metastatic lung or colorectal cancer, a staggering 74 percent believed that chemotherapy aimed at curing their illness.
Inherently, prognosis often entails a grim prediction of mortality, which can be unsettling for both patients and healthcare providers alike.
Nonetheless, I make it a priority to educate my terminally ill patients—almost all of whom are on dialysis—about their true prognosis. It deeply troubles me to witness individuals nearing the end of their lives receiving what I term "futile treatments," therapies that we all recognize hold no chance of success.
The Dangers of Over-Treatment in Modern Medicine
Due to a widespread lack of understanding about prognosis, many patients and their families often find themselves with unrealistic expectations from their medical teams, leading to instances of overtreatment.
In many Asian cultures, there exists a profound sense of guilt associated with opting for conservative treatment for loved ones facing death. Consequently, it is common for terminal patients, despite having poor prognoses, to undergo invasive procedures, be fitted with tubes, connected to machines, and sedated with medication—merely to prolong their suffering.
This scenario unfolds because some patients and their families may not fully grasp the nature of the disease, harbor unrealistic hopes, or have received inadequate information regarding long-term outcomes from their healthcare providers.
Research indicates that many Americans do not experience a 'good death,' meaning they do not pass away in the manner they would prefer—surrounded by loved ones at home. According to Medicare statistics, only about one-third of patients achieve this peaceful ending, while more than 50 percent die in hospitals, often in intensive care units, tethered to machines and feeding tubes, or in nursing homes.
How Doctors Approach Their Own Deaths Differently
Interestingly, a study led by Joel S. Weissman from the Centre for Surgery and Public Health at Brigham and Women’s Hospital in Boston discovered that physicians tend to approach death differently than the general population. They are less likely to die in hospitals (27.9 percent compared to 32 percent) and are less likely to undergo surgery or be admitted to intensive care during their final six months of life.
Why do doctors tend to die differently? It's clear that they possess a wealth of knowledge about the realities of death, including the fears that accompany it: suffering in pain, enduring aggressive interventions that may cause more harm than good, and facing the prospect of dying alone without family nearby.
Doctors are generally less likely to subject themselves to overtreatment. Personally, I aspire to die peacefully at home, with pain managed effectively by hospice care when my time comes.
Conclusion
I did inform Mrs. O of her impending death, but my commitment was to ensure that she could pass away with dignity and without pain. It is essential that I respect her final wishes and empower her to make informed choices regarding her treatment in her last days.
It is never my intention to subject any patient to overtreatment, which means applying aggressive measures that provide no real benefits, nor under-treatment, which involves withholding necessary care or symptom management.
My professional responsibility lies in striking a delicate balance. A critical aspect of my role involves communicating with patients as clearly and sensitively as possible about their overall prognosis, enabling them to make truly informed decisions that resonate with their personal values and objectives for the end of life.
By fostering open dialogue, we can ensure that the care provided aligns with the patient’s wishes, preserving their dignity until the very end.
