Honoring End-of-Life Wishes

Q. My elderly mother died recently of a cancer that was very advanced when discovered and is almost always fatal. She had often told us that she did not want aggressive hospital treatment for any terminal illness, to spare herself the pain and isolation and to spare her family (and society) the financial burden. But it didn’t work out that way. The quality of her life during the last few months was dismal, and the cost was huge. I accompanied her to every doctor’s appointment and took careful notes, and I am sure that the physician never clearly told us, in the first appointment after diagnosis, that her cancer was incurable and that she likely had just a short time to live. I know he didn’t mention home hospice care until near the end. How could this have happened?

A. Your mother’s experience is sadly common. Numerous medical studies have shown that most oncologists, despite improved training in end-of-life counseling, still don’t do it well with terminally ill patients. Many doctors don’t ask patients about preferred scenarios and don’t listen carefully to the responses, and they rarely talk about the palliative-care option in the first meeting.

Cynics suggest that doctors and hospitals have a financial interest in recommending aggressive therapies, or—in a more charitable explanation—they want to try out the latest cancer treatments to advance medical knowledge.

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But it’s not so simple. Physicians report that, even when they are clear about the prognosis, some patients don’t absorb what they are being told and remain in denial. And some patients and their families demand heroic treatment even when they are advised that the odds are poor.

In an ideal world, patients would state their wishes in writing long before their illness. And doctors would be very candid about the prognosis, ask the patient to repeat what he or she had heard, and follow up with a written summary of the talk. And the choice of hospice care—at home or in a caring, well-run facility—would be discussed from the beginning.

Have a money-and-ethics question you’d like answered in this column? Write to editor in chief Knight Kiplinger at ethics@kiplinger.com.