Memo From the Editor's Guest

"I think you're dying," my doctor said

By Louise E. Frazee, DO

He said those words slowly, his back to me, gazing out the hospital window at lacy snowflakes falling through a December sky.

A huge lump swelled inside my throat, and tears welled in my eyes. The world started to spin a bit. I gulped hard and said, "I'm okay on the dying part because of my faith. But I'm afraid to die a slow, painful death."

He turned to look at me. "I think it could be slow and painful," he said quietly. The world began to spin some more.

Giving other people this news is a difficult and dreaded part of my job. How ironic that at the tender age of 40 I would be hearing it from my doctor, my colleague, my friend.

My health has been gradually failing for the past 10 years, the result of a number of disease processes. Although any of the conditions might be treatable individually, the combination of maladies has made treatment very difficult and recovery much less likely. Although I seek care from the very best physicians I know, they are limited by what medicine can and cannot do.

My biggest personal challenge of the past decade has been learning to be a good patient while continuing to be a good physician. I certainly prefer treating others to being treated myself! The role of patient is uncomfortable: Life looks completely different, and I've become well- acquainted with fear. No matter what your background or training, an 18-gauge needle hurts when it pierces your body. And being wheeled into the surgical suite evokes a trembling unlike any other experience.

I've also had a chance to ponder an old question from a new perspective: How can we best help our patients who are dying? Many physicians are uncomfortable talking with patients about the approach of death. But it's as much our responsibility to care for patients in their final days and months as it is during the healthier times of their lives.

As a committed Christian, I have no fear of what will happen after death. But I do fear the earthly process of dying, the actual moment of passage from this world to the next. I don't want it to be prolonged or painful.

The most important thing a physician can do at such a time is simply to be willing to talk openly about death if the patient so wishes. The people who are most supportive are the ones who can step beyond their own discomfort at discussing my possible death and listen to me. This is hard on the person providing the support, but it's invaluable to me. Knowing that time may be drawing short, it's a huge relief to be able to voice fears and concerns without having to protect the person I'm sharing with. You'll never make things worse by asking your patients if they are afraid; in fact, it's a tremendous service to give them the freedom to express those feelings.

It also helps to maintain a sense of humor. I love to laugh. It's very healing, and we finally have studies that are documenting its therapeutic effect. Don't be afraid to joke and laugh with your terminally ill patients when the time is appropriate. The break will be welcome.

We also must go as far as we reasonably can in offering hope. Be an encourager. How many times have you seen a patient defy the medical odds because of a stubbornly positive attitude? It's always important to be honest about the prognosis, but try to be hopeful, as well. You can share the relevant statistics and survival rates, but a pat on the shoulder or a squeeze of the hand is more immediately helpful. So are remarks like, "I think you can beat this!"*

Patients take cues from their doctors. If you indicate that you expect them to do well, they probably will. When the time comes to let the patient know that the end of life is imminent, do so in a straightforward and kind way. Don't be afraid to show your own grief. Your patient will be touched and honored by a tear that glistens in your eye.

As medical professionals, we have the privilege of interacting with people as they prepare to leave this world. If we choose, we can help them make the easiest possible transition. It's no easy job, but it is truly a mission of mercy and an example of medicine at its best. Just listening and being there goes a long way.

PS: I've recently had to close my practice because of my health. My physicians hope that taking this step may reverse my downward trend and perhaps allow some recovery. Although leaving my patients was the most difficult and painful thing I've ever had to do, I think my health is improving. My physicians are great encouragers; they really help. With t heir coaching and God's grace, I hope to go far!

*See "Ethical hope—a lifeline for sick patients," Aug. 9, 1999.

Louise FRAZEE. Memo from the Editor's Guest.

Medical Economics

2000;5:8.