Her oncologist sent her in to the emergency room. The diagnosis was metastatic gallbladder cancer aggressively invading her liver, resulting in liver failure. I went down to the emergency room to see her. She only spoke Bengali, so every conversation required a phone interpreter. As I walked up to the patient’s bed I immediately noticed her jaundiced skin. Bilirubin, or breakdown products of red blood cells, above a certain level causes a yellowing of the eyes, the gums, and the skin where it deposits. It is frightening to see, the scarlet letter of illness.
It is unclear what the patient understood about her malady, as is so often the case when all communication occurs through an interpreter. Based on the notes in the chart, the oncologist offered chemotherapy merely as a palliative measure. No hope for cure remained, but the chemo might add weeks to the patient’s life by keeping the tumor at bay. Now, however, given the patient’s failing liver, any further treatment would kill the patient faster; it would hurt rather than heal.
But the patient expected chemotherapy. I told her this was unlikely but that we were going to admit her and see what we could do. Perhaps she had a treatable infection around the gallbladder, causing worsening inflammation and obstruction. Alternatively, was the cancer itself obstructing the liver’s ducts? If so, the gastroenterologists or interventional radiologists could place a stent to keep the duct open.
Ultimately, though, there was nothing to fix beyond the patient’s spreading cancer. No stent or antibiotics would help. Death approached, and chemotherapy would only hasten it.
Our medical team sat down with the patient and her family, using a phone interpreter, and explained the situation. But the patient, deaf to our explanations, repeatedly asked why she couldn’t get chemotherapy. Each of us in the room explained the same answer in a different way — the chemotherapy would make things worse, it would kill her. In short, the oncologist was not offering chemotherapy.
The patient broke down sobbing: “give me chemotherapy!” she cried in Bengali, “I want chemotherapy. ” “Please give it to me.” In between the tears we were silent. She was begging for something that didn’t exist — a cure. She was begging for a medication that would surely end her life.
In medical school I never learned the art of prognostication, the art of prophesying how much time was left in a patient’s life. Instead we learned how to “break bad news.” We role-played patient and physician and told each other about a cancer diagnosis. But we never addressed the reason any of these diagnoses were bad news. We care about the diagnosis because of the prognosis.
To be sure, it is difficult to teach the art of prognostication to medical students, who have limited knowledge and experience. How do you ask someone to prognosticate about a disease they’ve never seen? Moreover, different diseases follow different paths. I, for instance, am wholly unfamiliar with the typical course and treatment of lung cancer. I could not prognosticate about such a diagnosis. On the other hand, I am quite comfortable discussing the prognosis of various types of strokes. In other words, medical students have neither the knowledge nor the experience to engage in accurate prognostication. And yet, it is necessary to learn about it as early as possible, as so much of what our patients ask of us revolves around it.
In his book Death Foretold, Dr. Nicholas Christakis describes the importance of prognostication in medicine. He writes,
Predicting death is a way to counterbalance the sense of failure that arises when, despite the deployment of powerful technology in the care of the seriously ill, death cannot be prevented…. Patients and physicians alike believe that patients should have some general — albeit carefully circumscribed — awareness of death and its impending occurrence.
If a patient knows death approaches, he or she makes financial, spiritual, and filial arrangements. Such knowledge is indeed power, power to make one’s last days as meaningful as possible. Moreover, a prognosis allows patients to come to terms with a diagnosis. We need time to accept our own mortality. It is not akin to getting on and off a train.
Unfortunately, as Christakis points out, “physicians regard prognosis with anxiety and disdain, and they avoid it if possible.” We worry about prognosticating correctly. Many veteran physicians I admire make mistakes about a patient’s course. Such uncertainty checks my own confidence; I worry about hubris, about overextending the power of my profession. Christakis writes, “The great majority of physicians, 92 percent, are ‘reluctant to make predictions about a patient’s illness when the clinical situation is uncertain.’” And this reluctance grounds itself in reality. In a study conducted by Dr. Christakis and Dr. Elizabeth Lamont, only 20 percent of 468 doctor’s predictions were accurate. Most of these (63 percent) were overoptimistic. Fearing such inaccuracies, we avoid prognosticating altogether or hedge in our conversations with families.
According to Christakis, given its moral import, we oughtn’t avoid prognosticating. But using what we know we can recalibrate how we assess a patient’s timeline. We can be less optimistic and more realistic. We can ask our impartial colleagues to weigh in. And we can continue to study and publish on the prognosis of various diseases, allowing physicians to draw not just on their personal experience and training but on accumulated scientific knowledge. No study will perfectly characterize each individual patient’s situation, and no prognosis will be 100 percent accurate, but at least physicians can use scientific literature as a guide when prognosticating. And we must emphasize this to medical students.
I don’t know if my Bangladeshi patient truly understood the viciousness of her disease or the low likelihood of her survival. But those who understand what the outcome will be in advance have an easier time when the outcome arrives. They are no less sad about the ending. But they are, perhaps, more accepting. By prognosticating we help them come to terms with their mortality, allowing them to seek meaning at the end of their days. At the very least, they place hope in something not of this world rather than in a poison that will only hasten their end.