My patient’s chart was brief. A diagnosis of colon cancer that might have been cured had he not disappeared from medical care to return, nearly a year later, with cancer so advanced that it had torn through his intestines.
Colleagues at the hospital had called him to schedule appointments, to get follow-up and to start chemotherapy, but he never responded. Now he was back, but there was nothing the surgeons could fix, and so he would remain in the intensive care unit until his death.
When he arrived in our unit one night last winter, his cheeks were gaunt, his body wasted and abdomen protruding. He was also angry. As I remember the events of that night, as soon as the doctors in training and I gathered at his bedside to explain his prognosis, he lashed out. There was nothing wrong with him, he insisted. All he wanted was for us to treat his pain so that he could go home. He had things to do: a game to watch on television later that night.
As a critical care doctor, I am familiar with denial in its many permutations. I know how it feels to sit at a bedside and in windowless conference rooms, talking with families who cannot or will not let themselves acknowledge what is unfolding in front of them. We learn language to show that we are on their side, while also making it clear that things are not going to be OK. “I wish that the antibiotics were helping, but I worry that your loved one is dying,” we say.
But doctors can be far less equipped to deal with impenetrable denial from a patient. “I have to leave,” my patient said again, louder this time, seemingly unaware of the medications that ran through his veins, acting directly on his heart to raise his blood pressure. “Let me go,” he moaned, pulling at the lines that ensnared him.
I might have left the room then. I might have told him that we were going to do everything we could to get him home, even though I knew it would be impossible. I might have reassured him that things were going to be all right. But there was a part of me, standing there receiving his anger, that wanted my patient to know the reality of his situation. Even now, months later, I am not sure why.
What I do know is that I stood over his bed, distanced by my protective gear, and I told my patient the truth.
“I wish there were something we could do, but the cancer is too advanced. You’re dying,” I told him. I spoke loudly so that he could hear me despite the mask. He turned his head away, as if to avoid my words. I pressed on. “It could be hours now. I don’t think you will make it through the night.”
He flinched. The room was silent but for the sound of his heart rate monitor. The resident doctors looked toward me, trying to disguise their own surprise. I think each of us wanted to take the words back. To tell him that sometimes we are wrong and that maybe he wasn’t dying after all, but it was as if we were frozen.
He yelled, “Get out!” with all that his failing body could muster. He didn’t want any more of our lies. He just wanted to be left alone.
Outside, I took a deep breath. My hands were trembling. Later that night, I learned, my patient’s family arrived — a long-estranged sister and son. By then he was fading away, but they turned the hospital television to the game he had wanted to see and watched together as he died. I never had the chance to talk with him again.
For the next few days, I kept returning to that moment at the bedside. What had I hoped to accomplish? As a doctor and purveyor of science, it can be difficult to accept that sometimes the “truth” is not what a patient needs. Denial was my patient’s only defense mechanism. And as soon as the words left my mouth, I realized how cruel it was to try to take this defense from him in the final hours of his life.
I pride myself on being gentle with my patients and their families, even the “difficult” ones, who demand interventions that we cannot offer and believe steadfastly in a recovery that will never come. In the intensive care unit, we have the honor of caring for people at their most naked and frightened. I try to recognize the emotions in front of me without drowning in them.
But in that moment, I was not gentle. And as I revisit that night, I wonder about why I responded as I did and how we doctors react when faced with people who are dying because of bad decisions about their health.
In the most generous version of that night, my goal was to give my patient the information he needed so that he could reach out to those he loved, to say whatever he would want to say with the knowledge that his time was short. That was one piece of my response. But I also responded to him with my own anger, at the avoidable nature of this tragedy, at how denial had turned deadly. This man was scared and he was going to die of a disease that might have been cured. And I could do nothing about it. When I told him that he had only a few hours to live, I allowed my frustration to obscure the reality of his suffering. And I caused harm as a result.
In most contexts, it is a doctor’s responsibility to tell our patients the truth, to help them to understand even the most devastating realities. But when I think about that night, I know that I added to my patient’s pain in the last hours of his life. I wish that I had done it differently. I could have paused and told him that yes, he was going to go home. I could have simply been there with him and said nothing at all. That small kindness might have done more for him than the truth.
Daniela J. Lamas (@danielalamasmd), a contributing Opinion writer, is a pulmonary and critical-care physician at Brigham and Women’s Hospital in Boston.
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