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    Thursday, August 12, 2004

    Rationing Resources: The letter from a cancer patient's husband that prompted DB's post about the doctors and dying patients (see last post from Aug 11), has gotten under my skin. The letter was published by the New York Times in Jane Brody's weekly health column, in the hope that doctors everywhere would take note and be kinder to their dying patients. Here's the letter in its entirety:

    Dear Doctor: I'm writing to you in reference to my wife, who died on May 29, 2004. I wish to make clear from the outset that I am not impugning your medical competence but am seeking to bring to your attention what, in my opinion, constitutes a grave breach of the moral contract you entered into with her.

    "As you know, my wife was diagnosed with lung cancer in 1997 and was treated successfully by you for almost seven years. During that time, she developed a relationship of confidence with you which, given her many unhappy past experiences with doctors, was both encouraging and surprising.

    "And yet, at the end, to her (and my) profound disappointment, you failed her. When you realized that you could do no more to reverse her progressive disease and that death had become inevitable, you abandoned her. You evaded her telephone calls; you waited 10 days before informing her of the April 2004 CAT scan results; you pulled away. The empathy you had displayed was replaced by what she experienced as indifference. And, sadly, your behavior dovetailed perfectly with the New York Times article "Facing Up to the Inevitable, in Search of a Good Death" of Dec. 30, 2003, which speaks of physicians who withdraw from patients rather than address feeling 'guilty, insecure, frustrated and inadequate.'

    "It is true that you informed my wife, offhandedly, that the hospice staff would care for her during the final phase. As they did - with dedication and great dignity. However, your coldness during her final weeks made it more difficult for us because she felt that she had lost the medical anchor you had provided and no longer had a doctor she could trust to explain what was happening to her as her body withered and her vulnerability grew.

    "Much precious time was wasted trying to turn her mind from your dismissal of her that she experienced as a professional and personal betrayal. Which I believe it was.

    "Would it have cost you so much, doctor, to have picked up the telephone to speak with her after almost seven years of treatment? Would it have been so intolerable to you to have looked into her eyes - at the hospice perhaps - and told her that you wished her well and wanted a chance to say goodbye? Were you truly unable to offer even a shred of comfort, a word of condolence to her family? Had she really become no more than another statistic, a failure you preferred to brush aside?

    I am asking you to help ensure that oncologists like yourself, who work with many patients they are bound to lose, not abandon them emotionally, as you did. I am asking that you suggest that your hospital consider setting up a training program for doctors like yourself so that other patients can be spared the pain of the rejection my wife experienced. Because it is my conviction that doctors treating terminally ill patients have a moral obligation to stand with them from start to finish even when, at the end, those patients must be transferred to hospice care. It is not easy for me to tell you that from this perspective, I believe that your failure was monumental.

    "Perhaps this letter will help you display greater feeling with future patients and not ask them, as you did my wife from a distant height, 'What would you like us to do for you?' What she wanted you to do was simple: she wanted you to speak to her with courage; she wanted you to show a bit of concern, which would have meant as much to her then as all the chemotherapy you prescribed when there was still hope; she wanted you to help her die more peacefully - as you had promised that you would but did not. It would have made the work of the hospice staff easier. It would have been a consolation to her and to the family and friends who loved her.

    It's a very eloquent and moving letter. Any doctor with a conscience would be devastated to receive it. The thing is, there's probably not a doctor anywhere on this earth who hasn't caused a patient, usually inadvertently, the same emotional pain.

    In most cases, it's not that we don't care, but that our attentions are required elsewhere by patients with more urgent needs. It's not so uncommon. I had a patient accuse me of being uncaring because I left the exam room during one of her visits. I don't make a habit of this. My staff only interrupts me for emergencies. In this case, it was another patient having a heart attack. It didn't matter to the first patient, though, she couldn't see beyond her own needs - and she left me because of it.

    I remember another case, during residency, that happened to one of my fellow residents. It was during his intensive care rotation. One of his patients was scheduled to have an invasive procedure the next day and was very anxious about it. My fellow resident was a very conscientious and sensitive person, and he spent a great deal of time trying to console and reassure the patient. But he wasn't very successful. The patient kept asking the nurses to page him throughout the night so he could ask questions and get more reassurance. But my colleague had a lot more pressing matters to attend to that night - patients who would die if he ignored them. He finally said (in exasperation) to the anxious patient, "Look, I don't have time to spend all night holding your hand." A cold and uncaring comment, yes, but one uttered by a doctor at the end of his rope. It bothered him a lot - that's how I know about it. He felt so bad that he included it in his report at morning rounds. It was also a turning point in his career. He left family medicine and became a psychiatrist.

    And that's what bothers me about this letter. The patient obviously expected more from her doctor than he could give, and assumed that his failure to meet her expectations was due to a deficiency of his character. But it was more likely a deficiency of his time. Only comic page doctors have the unlimited time to devote every waking hour to one patient.

    UPDATE: 100% of readers disagree with me on this. A couple of samples:

    I think you gave yourself an easy out by stating that doctor's are just too busy to continue being involved in their terminally ill patients lives. Yes, time is a cruel mistress and none of us have enough to go around, but a simple call or even saying goodby would not have left this patient with a sence of guilt that they had done something wrong by dying.


    I understand your concern for doctors who have so little time and have to do so much, but here's the sentence from the husband's letter that bothered me:

    "you waited 10 days before informing her of the April 2004 CAT scan results;"

    Due to serious illnesses in 3 family members, I have had experience with nearly a hundred doctors - good and bad, caring and unkind - from Maryland to California. That sentence makes me believe this man's concerns are well-founded.


    posted by Sydney on 8/12/2004 09:07:00 AM 0 comments


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