While many people avoid conversations about death, others are surrounded by it every day.
As an hematologist and oncologist, Dr. Jalal Baig often has to inform a patient, or their family, they are going to die.
“One thing to realize is that 70 percent of physicians claim to have never received any training in having end-of-life care discussions,” Baig said Wednesday on WBEZ’s Morning Shift. “And at least 50 percent say that they’re not comfortable having that discussion — or they don’t even know how to initiate that discussion.”
Baig, a hematology and oncology fellow at University of Illinois-Chicago, said he chose oncology — the study and treatment of tumors — because of the relationship he can form with his patients, often seeing them from diagnosis through treatment to either remission or death. While Baig said medical school prepared him to treat these diseases, it didn’t prepare him to talk to his patients about dying. He said he had to learn that on the job.
Baig spoke with Morning Shift host Tony Sarabia about his experience talking with patients about death.
How talking about death is taught in medical school
Dr. Jalal Baig: I think more and more medical curriculums are starting to embrace the need for end-of-life care discussions. Absolutely. The conversation nationally is evolving in that direction. But medical school doesn’t do more than a token lecture — maybe one or two lectures — that are just abstract, theoretical PowerPoint slides that you look at. Maybe you do a couple modules here and there on the computer. But nothing really trains you for the raw emotions and the experience of walking into a room when a patient is acutely deteriorating, and having to confront a family that’s panicked — has fears, has anxiety — is desperate. Nothing prepares you until you actually walk into the room as a physician once you’ve graduated.
Tony Sarabia: And you’ve done that?
Baig: You have no choice but to do that.
His experiences telling a patient of his or her impending death
Baig: When I’ve walked into a room, let’s say in the intensive care unit or on a cancer ward, and a patient is acutely deteriorating — their blood pressure is dropping, they’re having extreme difficulty breathing and a decision needs to be made at that time whether to put a breathing tube in, whether to escalate care, situations where a patient loses their pulse or stops breathing and you need to decide whether a breathing tube needs to be placed in, whether you need to start chest compressions — and unfortunately a lot of patients have not had that discussion prior to their admission to the hospital.
And when they acutely deteriorate, you’re trying to call the family, trying to cobble together some kind of answer. And in that acute setting, fear sets in. The family says, “do everything,” without really fully appreciating the implications of that decision.
That’s where most of my discussions have occurred so far, unfortunately: in the acute setting where fear takes over and really rational decisions and a good meaningful discussion is very difficult to have.
How patients react to end-of-life conversations
Baig: It’s obviously a very difficult conversation to initiate.
Sarabia: Why is that?
Baig: Because you’re essentially telling someone that they’re dying. And that’s difficult enough, and you’re telling them that there’s nothing else that we can do. And a lot of the research and the studies that have been done show that when physicians have this conversation, a lot of them will over-estimate the amount of time that patients have. And they’ll neglect that conversation for that reason.
In other situations, a lot of physicians will tell an individual that they have an incurable cancer, but will never give the full prognosis, so they’ll withhold some of that information.
The process is more than one conversation
Baig: It’s important to realize in these conversations that this is actually a process. It’s not an epiphany that happens for a patient, and you can’t just give facts and objective data to a patient and say, you know, “You’re dying. No more treatment options are available. Chemotherapy isn’t working anymore. Do you want a breathing tube? Do you want chest compressions? And do you want hospice?” That is not a very sincere, sympathetic process. And so when I say this is a process, not an epiphany, you have to sit down and really ensure that the patient understands what his or her prognosis is. You have to ask what his or her fear, concerns are. In addition to that, you have to ask them what are their wishes or goals if their disease continues to progress. And, finally, what tradeoffs are they willing to make and not willing to make.
That conversation cannot happen, like I said, in an acute setting where someone is deteriorating. That needs to happen when someone is fully lucid inside your clinic and has decision-making capacity.
Are oncologists an optimistic bunch?
Baig: I think they have to be. Essentially to deal with a disease in which a lot of patients have terminal cancer and incurable disease, if you are not an optimistic individual you cannot impart optimism in any way to your patients. It’s very hard to feign optimism for a long period of time and I’ve found — I’m almost one year into my fellowship now — you cannot fake your optimism. You truly have to believe it and personify it.
This interview has been edited for clarity and brevity. Click the ‘play’ button to hear the entire segment.
For more from Morning Shift's weeklong series on discussions about death and dying, visit wbez.org/deathconvo.