How to approach mortality with elderly patients
Dr Robert Glynne-Jones - Mount Vernon Hospital, Middlesex, UK
You’re a cancer doctor and supposing you have a patient, you know that they’re not going to live, you don’t know how long they’re going to live but you can’t offer them a cure. How do you approach with an individual patient the prospect that at some point they will die?
This is a conference on the elderly patients and taking the notion that death may be relatively close is obviously more a reality for elderly patients than for younger patients. So it does depend to some extent on the age of the patient but it’s very important, right when you start, to clarify what the aims of the treatment are. So if the aims of the treatment are for cure then you talk about cure but if they’re not then you say, ‘Right, we don’t think that we can make this go away and not come back. Our aim…’ and you make sure that that is an agreed aim between you, ‘The aim is to get you well and keep you well as long as we can.’
Do you find that it’s difficult talking about the actual length of someone’s life? Doctors sometimes say, ‘Well, you’ve got so many months to live,’ that’s presumably not the right thing to say?
I don’t know, patients ask you, they do. But it’s interesting that you might look after a patient for many months and then one day the patient says, ‘So how long have I got, doctor?’ Or they might ask you that on the first…
How do you cope with that?
If you’ve seen them for a long period of time and they suddenly ask you, ‘So how long have I got, doctor?’ and it’s a real question and you know it’s a real question, you can say, ‘I’ve been looking after you for a long time, so how come you want to ask me that today? What is driving that today?’ And sometimes you find things like, ‘Well, I’m beginning to realise that if I’m going to go and visit my daughter maybe I should go and do that and I need to know, I need to have some definition of how long I’ve got to live.’ The problem is that to start with many patients want to, although they’re aware of that, they want to hide it. When I was a junior doctor I had a job where I didn’t earn much money and so one of the bills came in and it was this huge mortgage bill, a monthly bill coming in, and I put this into my desk, in the drawer of my desk, and my wife said, ‘What are you doing that for? It’s not going to go away.’ And I said, ‘Well, no, I know it’s not going to go away but I’d rather look at that when my salary comes in.’ I think we’re all a bit like that, that we may be aware of things but we don’t want to look at it right now.
So what tactics do you use as a doctor because some patients might say, ‘How long have I got to live, doctor?’ but they don’t really mean it, they want you to say, ‘Oh well, quite a long time.’
You’re right that some patients ask you how long have I got because they want to hear something different to what everyone… If the surgeon says, ‘Well in my general experience you’ve got six months or so,’ they may want to hear something better than that. So there are some patients that root around and ask every single individual professional they come across the same question and then when they get a slightly better answer they kind of take that, ‘Oh, I’ll have that one, thank you.’
And, of course, you have a team, you’re working with a team, the patient may well ask someone much different from the doctor because the doctor is an awesome figure.
You’re right that having a team and having lots of different individuals in the team who inevitably will have different opinions and different views clouds the issue a bit. I think you’re absolutely right there, in a way if we had time we would have a briefing, a proper briefing, before every clinic. So you would actually be able to brief every individual about that particular patient, sadly we don’t do that.
How many patients really do not want to know that their death is imminent?
I don’t know that I could give you a figure but you get different kinds of consultations if the patient is on their own and if the patient is with relatives because whatever the patient says with a relative there, if you start getting to those sorts of questions about how long have I got with a relative there then you often make the relative cry. So some of the issues are… it’s an issue about I want to protect my relatives. If the relative goes out of the room you have a much more in depth and honest consultation.
And if you think that it would be useful or helpful to the patient to know that their time is limited, how do you broach the subject?
I’m not sure that that’s my prerogative to push the agenda. Patients want to know, I will really go at the patient’s pace. Sometimes you get the sense that there are questions that the patients wants to ask but doesn’t and so you can say, ‘Is there anything else you want to ask me, I get the sense that something is bothering you today or there’s something unresolved about the consultation today. Are you sure there’s nothing else?’ And you can push that a bit, you can push it with silences that you can put the question out there and then you don’t say anything for a while so they’re forcing silence. So sometimes you can do that, sometimes you can manipulate things that you take them off to another room to examine them away from the family and then they will ask you things in a much more personal way because there’s just the two of you and the family aren’t there to upset. Sometimes they want to know things that they don’t want the family to know.
How do you cope with the fact that the patient regards you as almost the centre of their universe as their specialist and yet you might well palm them off to palliative care later on?
I don’t really like the word palm off to palliative care; I do involve palliative care. Personally, and this may sound an intuitively poor thing to do, but I will still see the patients even though they are… In my clinic in Barnet, which we talked about, I have a palliative care doctor in the same clinic in a different room and usually I will say to the patient, ‘Look, we’ve come to the end of chemotherapy, there is no more chemotherapy that I can give you and I think we need to involve palliative care.’ But I think one of the really powerful things is to say, ‘But I won’t give up on you, I will still see you, I will not give up on you.’ Those are some very powerful words because it kind of means the guy isn’t, as you say, palming me off but that’s a bit of an indulgence, I admit.