Air date: August 9, 2009

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The intern was clearly shocked as we sat in the physicians’ workroom after talking to Mr. Smith. "I didn’t know he was dying," the intern said. I sensed he felt that I had been less than truthful. But, as is often the case, there were several truths towards the end of Mr. Smith’s life. There was the truth of what Mr. Smith and his family hoped for. There was the truth of what I expected to happen. And finally there was the truth we came to share.

The truth found in our hopes for the future is potent and yet somewhat elusive. Gravely ill Mr. Smith had been admitted to the hospital eight days before with pneumonia and recurrent acute leukemia. The chance for meaningful recovery was minimal. But it was not zero. So we administered antibiotics, oxygen, and transfusions. And our limited medical goals were transformed to the first vital step towards a son’s wedding, the peak season of the family business, and a life unconstrained by illness or doubt. Life, in a word, restored.

But I anticipated that he would die soon. And, for me, within that expectation lay a larger truth. I did not want Mr. Smith and his family to experience the heartache of unrealistic expectations or the physical burdens of futile medical care. I wanted to preserve his ability to truly choose how he spent the final weeks of his life. Thus, my daily visits with Mr. Smith were, only in part, to assess his physical condition. The most important goal was to develop a shared sense of whether we were moving towards or away from our immediate treatment goals. If we were moving away then what different futures did we need to imagine and to plan for?

Earlier on rounds with the intern, Mr. Smith had indicated that, for the first time, he wanted to talk about dying at home. It was only then that I knew his impending death had become our shared truth. "I believe we just discovered he was dying," I explained to the intern. "Next time I will know the prognosis better," the intern said tapping the side of his head lightly.

Prognosis -- the predictions physicians make about the medical future -- occupies an almost magical space within medicine. We seek to reduce or make manageable the uncertainty with numbers expressed authoritatively. But there is always the person. Mr. Smith may have insisted that "not zero" was a chance, that my concerns about futility were irrelevant given his desires to live. I might have encouraged him to receive intensive therapy, to accept the risk, to trust that maybe this time around we would do better. But the final truth, in this instance, was that the inconceivable -- that Mr. Smith would die despite all he had chosen to endure, all the time, energy and faith he had chosen to invest -- became the conceivable. It became the truth upon which we made plans to care for him as he was dying.

"Knowing may be more a matter of the heart," I finally replied the intern spreading my hand across the center of my chest.

Additional Resources:

• IU Simon Cancer Center

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