Everybody Dies: Let’s Be Honest with Ourselves

Everybody Dies: Let’s Be Honest with Ourselves

David L. Graham, MD, FASCO

May 14, 2013

Our practice recently had a visiting speaker sponsored by a pharmaceutical company speaking on a new drug for the treatment of metastatic colorectal cancer. As part of the presentation, a Phase III randomized trial was presented demonstrating an improvement in median survival with the use of the drug in patients with widely metastatic disease.

A specific part of the slide jumped out at me. For some reason, a hazard ratio was calculated and included on the slide. The speaker cited the hazard ratio of 0.68, and then stated that using this drug meant that these patients had a “32% less chance of dying.” This was said while standing in front of survival curves that both quickly went to zero. Other than wondering why someone thought calculating a hazard ratio in this situation was the right thing to do much less putting it on the slide, an important idea came to mind.

Make no mistake; no one involved in this trial was prevented from dying. No trial has ever prevented anyone from dying. No treatment we give keeps anyone from dying. Everybody dies. This is important enough to warrant emphasis . . .

Everybody dies.

So how do we, as oncologists, react to this? I would suggest there are two ways we approach the idea.

The first way is a bit egocentric but probably used the most often. That is to say “not of my disease.” We have all happily told patients “something else will probably get you first.” As long as a patient passes away of something other than their cancer, we feel we have done our job. I don’t mean to say this in a criticizing fashion. It’s just reality, and it’s ok to see this as success.

There comes a point, though, for many of our patients where “dying from something else” is not going to be the outcome. We clearly know that they will likely die of “our disease.” Our job then changes. The imperative then should become to make that end as reasonable and humane as possible. Part of that is being honest with the person about their situation. It’s not easy and it is rarely successful on the first go. It is, though, important.

I can see how this approach might be viewed as crass and somewhat overly blunt. It is certainly an idea that raises a few eyebrows when I discuss it with medical students or residents. They really are not used to thinking of things in this way. We should be honest with ourselves, and our patients certainly deserve nothing less.


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David M. Baer, MD, FACP

May, 25 2013 12:08 PM

Very nicely put.

We do not do a good job explaining the benefits and risks of our interventions in terms our patients understand. It starts with the way we talk about them to each other. There is a lot of room for improvement. 

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