The Magic Words: How Long Have I Got to Live? And Other Questions

I’ve been a practicing physician for 20 years now. In this series, I’m sharing some of the best practices and helpful phrases I’ve learned for talking about bad news and end-of-life issues with patients.

Know your limitations

In Part 3, I recommended preparing patients for future changes by gently warning them of the possibilities. A bump in the road is something I can predict. My favorite oncologists will say, “A side effect, or an infection, or something else is pretty likely, so let’s just expect it. Don’t be discouraged if that happens.” I can predict that might happen … but there’s a lot I just can’t know. Often, when asked about a disease or chemotherapy-specific issue, I need to defer to specialists. I don't know how well such-and-such chemo works. I don’t pretend to. I’m also often asked to predict survival. This is the most common request: “Just tell me how long I’ve got, doc.”

Truth is, we don’t know.

Every time someone gives an estimate or an average survival, they’re guessing, and they’re wrong (e.g., “six months”). I never do that. I follow the example of palliative care doctors who’ve told my patients that they’ve got years, months to years, weeks to months, days to weeks, or hours to days left to live. And I emphasize the outliers. “I’ve met people with metastatic cancer who lived years longer than expected,” I told a woman I was discharging from the hospital later that day. “And other times, an unexpected accident, infection, or deadly blood clot can shorten someone’s life without warning. But most people in your situation can expect to live weeks to several months.” She had advanced ovarian cancer. I suspected that it would strangle her bowels, prevent her from eating and drinking, and force her to dwindle.

Three hours later, after we had already called for ambulance transport home, my patient decompensated. A medical student helping me take care of her texted me her vital signs, asking, “Is this concerning? Should we still discharge?” My eyes went wide when I saw them. I swallowed a last bite of lunch and jogged to her room. I knew I might not make it to her room before she died. On my arrival, she had agonal respirations and had become nearly unarousable.

“Should we give more morphine?” the student asked. “Sure, let’s try,” I answered. “We might have time still.” She was gone within minutes.

Patients with cancer are predisposed to deadly blood clots. Reduced activity and chemicals made by tumors are the biggest reasons why. My guess is my patient had one, and it traveled from a leg vein to her lungs, where it stoppered the flow of blood to her left heart and onward to her vital organs. I’ll never know for sure. I just know she reminded me of the impossibility of predicting longevity.

Keep it simple

My medical school teachers taught me that patients don’t remember a thing after they hear the word “cancer” the first time.

But we can do several things about that. The first is not to overload them. As I’ve said, disclosure and planning are processes, not one-time events. Just give them the bad news, on that first, terrible day. Sometimes that’s all you should expect to do.

But if you’re sharing more, you can write it down. And normalize the fears and questions that all patients receiving bad news invariably have. Here’s what I tell them: “You know, in medical school, I had to read my notes at least five times to understand them, and I wasn’t sick then. No one can get this all in the first discussion. I’m taking some notes for you, just the key points, and you can look these over and ask us more questions, or the same questions, tomorrow. We expect you to have more questions.”

Because they will. Because you need to give them permission to ask those questions. Because getting terrible news feels like drowning, extend a hand.

Thanks for reading. It’s been quite a journey and privilege taking care of amazing people at some of the critical and vulnerable moments of their lives. I hope these pieces have been helpful to those facing cancer and other serious diagnoses. In the next entry in this series, I’ll tackle the difficult situation of a patient who wants “everything,” when that would mean painful and futile treatments.