Over the course of a career, an oncologist may have to deliver 5,000 death sentences or more. The prospect is so daunting that as recently as 50 years ago, many refused to do so. Today, it's an ongoing struggle to marry the truth about the present and hope for the future.
However, a new U.S. study suggests that hope itself can harm patients.
The University of Michigan's Dr. Peter Ubel and several colleagues followed patients who had their colons removed. One group knew the procedure was permanent and that they would rely for the rest of their lives on colostomy bags. A second group were told that after a period of healing, their bowels could be reattached.
After a few weeks, both groups were struggling. But six months later, the group that had been permanently disabled showed far more life satisfaction on a survey. The group awaiting a reversal procedure remained depressed and unhappy.
"They knew things would get better, but that made them less satisfied with their present circumstances," said Ubel. "While usually a good thing, we see that hope has a dark side."
He likened it to the difference between prison inmates with finite sentences and those jailed for life. Studies have shown that prisoners who know they will be released are more likely to attempt escape.
"They keep imagining life outside prison," said Ubel.
The lifers are resigned.
"One of the reasons that hope is damaging is that people hope for things that are impossible," said Dr. David Casarett, a senior fellow at the University of Pennsylvania's Center for Bioethics. "Our job as physicians is to point people toward the sort of hope that is achievable."
Casarett works as a hospice physician. Virtually every patient he's treated in 10 years of practice is dying, and knows it. He recounted that while a small majority "freeze" after the diagnosis, many others find meaning in end-of-life projects. He's compiled a collection of those stories in his upcoming book, Last Acts.
Bad news has a generally bad history in the medical profession. A landmark 1961 study showed that 90 per cent of American oncologists routinely refused to discuss cancer diagnosis with their patients.
A sea change in that attitude began about 30 years ago, thanks to pioneering physicians like Dennis Novack and Toronto's Robert Buckman.
"Even if the news is bad, even in some respects hopeless, it allows you to know what you're dealing with, and you can cope," said Buckman, an oncologist at Princess Margaret Hospital. Buckman is the author of a widely used textbook on the subject, How to Break Bad News: A Guide for Health Care Professionals.
A similar poll taken by Novack in 1979 showed that 97 per cent of doctors now preferred to deliver the truth. But there are varieties of truth — and if they are unprepared, doctors may have difficulty summoning the unvarnished variety.
Buckman teaches a process he calls SPIKES (Setting, Perception, Invitation, Knowledge, Empathy, Strategy). It boils down to inviting the patient into the process ("How much information would you like me to give you about your diagnosis?") and then clearly spelling out both the diagnosis and prognosis. At all points, the physician reacts to the patient's state, rather than trying to control their own.
"I don't think I'm an empathic person myself," said Buckman. "But when I'm looking at the patient, I try to think, 'What emotion are they going through?'. And then I acknowledge that. Empathic responses can be learned."
Rather than ignore the truth, as doctors once did, or deliver false promises, Buckman advises the physicians to speak plainly, and with compassion.
"Hope is not a monolith. It's not one thing," said Buckman. "If the disease cannot be cured, that hope is gone. But there are many others — not being abandoned, being free of pain, being able to talk easily to your family, being able to go on a trip.
"All of our lives are made up of a thousand small hopes."