Truth in the Most Optimistic Way

• Prognosis
• Physician-patient relations
• Hospice care
• Physician practice patterns
• Terminal care

While I was in residency at the Mayo Clinic, my oncology attending arrived for rounds one day with a sheepish grin on his face. It was June 3rd, you see, and for the 7th straight year a former patient of his had called him and angrily exclaimed, “I am still alive, you idiot!” before slamming down the telephone. Seven and a half years ago, the oncologist had given the man 6 months to live.

Since then, I have stopped giving patients specific predictions about their life expectancies. I recognize that patients need to know their prognoses to make treatment decisions and plan their affairs. However, I have found that relatively nonspecific prognoses are sufficient. I might say, “I cannot predict the future, but in my experience, patients with your illness typically live a matter of months, not years,” or “Many people in your condition will live for only a matter of weeks, but some live significantly longer. I do not know what your fate will be.” In these conversations, I discuss concrete treatment goals with patients. I do not hesitate to say when I think the goal should shift from cure to palliation. When things are grim, I suggest that it is time to visit with friends and family because “it is better to be safe than sorry.” I give enough prognostic information to help patients make decisions, but I avoid using numerical wording that suggests I have a prognostic crystal ball.

In this issue, Lamont and Christakis (1) report the results of a survey of physicians who had referred patients with cancer to local hospices. They asked each physician …