Dealing with Doctors, Denial, and Death

1. Accepting death's inevitability allows for better end-of-life decisions

If we think about our life and death, even in a general way, we might understand that planning for our life before death is a useful process.

Confronting mortality. Denial of death is a common psychological defense mechanism, but it can lead to unnecessary suffering at the end of life. By acknowledging death's inevitability, patients and families can make more informed decisions about medical care, focusing on quality of life rather than prolonging life at all costs.

Cultural shifts needed. Our society often sanitizes and avoids discussions about death, making it difficult for individuals to face their own mortality. Changing this cultural attitude requires open conversations about end-of-life wishes, both within families and in the broader community. Healthcare professionals play a crucial role in facilitating these discussions and helping patients understand their options.

2. Honest communication between doctors and patients is crucial

Communication—honest and complete—between doctors and patients is essential for the good and appropriate care of every patient.

Breaking bad news. Many doctors struggle with delivering difficult information to patients, often resorting to euphemisms or avoiding the conversation altogether. This lack of clarity can lead to unrealistic expectations and unnecessary treatments. Training in effective communication techniques is essential for healthcare providers.

Informed decision-making. Patients need clear, jargon-free explanations of their condition, treatment options, and prognosis to make informed decisions. This includes:

• Realistic assessments of treatment efficacy
• Potential side effects and quality of life impacts
• Alternative approaches, including comfort care
• Opportunities for questions and clarification

3. Religion and spirituality can provide comfort, but shouldn't dictate medical choices

Accepting death and making the time before death peaceful and comforting is one of the best gifts we can give to ourselves, our family and our loved ones.

Balancing faith and medical reality. While religious beliefs can offer solace and meaning during illness, they should not override medical expertise or lead to futile treatments. Healthcare providers should respect patients' spiritual needs while still providing honest assessments of medical situations.

Addressing spiritual needs. Studies have shown that patients whose spiritual needs are addressed by medical teams are more likely to accept comfort care and die peacefully. This highlights the importance of:

• Integrating spiritual care into medical treatment plans
• Collaborating with chaplains and religious leaders
• Respecting diverse beliefs and practices

4. Patient autonomy must be balanced with medical expertise

Patient autonomy is important for good medical care, but it has its limits.

Informed choices. While patients have the right to make decisions about their care, these choices should be based on a clear understanding of medical realities. Doctors should provide expert guidance and recommendations, not just present options without context.

Overriding futile treatments. In some cases, medical professionals may need to refuse treatments that are clearly futile or harmful, even if requested by patients or families. This requires:

• Clear communication of medical reasoning
• Empathy for emotional factors influencing decisions
• Involvement of ethics committees when necessary
• Legal and institutional support for such decisions

5. Advance planning is essential for ensuring end-of-life wishes are respected

Four out of five Americans do not prepare the necessary paperwork, in what is called an advance directive, to guide their physicians and families if they become so seriously ill that they themselves become incapable of expressing what they want.

Advance directives. These legal documents allow individuals to specify their preferences for end-of-life care, including:

• Do-not-resuscitate orders
• Preferences for life-sustaining treatments
• Designation of a healthcare proxy

Ongoing conversations. Advance planning should be an ongoing process, not a one-time event. Regular discussions with family members and healthcare providers about evolving wishes and values ensure that care aligns with current preferences.

6. Overtreatment often stems from doctors' training and societal pressures

Even though it can be difficult to decide whether a treatment is appropriate and when it becomes "over-treatment," it is clear that many doctors recommend or go along with treatments that are not in patients' best interest and are not going to help them.

Medical culture. Doctors are trained to fight disease aggressively and may view death as a failure. This mindset, combined with fears of lawsuits and financial incentives in the fee-for-service system, can lead to overtreatment.

Systemic issues. Overtreatment is perpetuated by:

• Specialization leading to fragmented care
• Pressure from pharmaceutical and device manufacturers
• Public expectations fueled by media hype
• Lack of training in end-of-life care

7. Comfort care and hospice offer alternatives to aggressive treatment

When faced with fatal or life-altering illness, two major psychological responses occur. The first could be called a "numb" feeling. [...] The other common response is that of denial.

Shifting focus. Comfort care and hospice prioritize quality of life over longevity, focusing on:

• Pain and symptom management
• Emotional and spiritual support
• Family-centered care
• Allowing death to occur naturally

Benefits of early referral. Studies have shown that some patients with advanced cancers live longer and with better quality of life when referred to hospice early, compared to those receiving aggressive chemotherapy.

8. Aid in Dying (AiD) provides a humane option for terminally ill patients

Having control over their deaths gives patients assurance that they can end their suffering when they choose.

Legal and ethical considerations. AiD is currently legal in several U.S. states, allowing terminally ill patients to request life-ending medication from their doctors. This practice:

• Respects patient autonomy
• Provides an option for those with intractable suffering
• Includes safeguards against coercion or misuse

Broader impacts. The debate around AiD has increased awareness of end-of-life issues and improved overall palliative care. Many patients who receive prescriptions for life-ending medication never use them, finding comfort in having the option available.

Last updated: August 10, 2024