Skip to main content

Main menu

  • Home
  • Content
    • Current issue
    • Past issues
    • Early releases
    • Collections
    • Sections
    • Blog
    • Infographics & illustrations
    • Podcasts
    • COVID-19 articles
    • Obituary notices
  • Authors & Reviewers
    • Overview for authors
    • Submission guidelines
    • Submit a manuscript
    • Forms
    • Editorial process
    • Editorial policies
    • Peer review process
    • Publication fees
    • Reprint requests
    • Open access
    • Patient engagement
  • Physicians & Subscribers
    • Benefits for Canadian physicians
    • CPD Credits for CMA Members
    • Subscribe to CMAJ Print
    • Subscription prices
    • Obituary notices
  • Alerts
    • Email alerts
    • RSS
  • JAMC
    • À propos
    • Numéro en cours
    • Archives
    • Sections
    • Abonnement
    • Alertes
    • Trousse média 2023
    • Avis de décès
  • CMAJ JOURNALS
    • CMAJ Open
    • CJS
    • JAMC
    • JPN

User menu

Search

  • Advanced search
CMAJ
  • CMAJ JOURNALS
    • CMAJ Open
    • CJS
    • JAMC
    • JPN
CMAJ

Advanced Search

  • Home
  • Content
    • Current issue
    • Past issues
    • Early releases
    • Collections
    • Sections
    • Blog
    • Infographics & illustrations
    • Podcasts
    • COVID-19 articles
    • Obituary notices
  • Authors & Reviewers
    • Overview for authors
    • Submission guidelines
    • Submit a manuscript
    • Forms
    • Editorial process
    • Editorial policies
    • Peer review process
    • Publication fees
    • Reprint requests
    • Open access
    • Patient engagement
  • Physicians & Subscribers
    • Benefits for Canadian physicians
    • CPD Credits for CMA Members
    • Subscribe to CMAJ Print
    • Subscription prices
    • Obituary notices
  • Alerts
    • Email alerts
    • RSS
  • JAMC
    • À propos
    • Numéro en cours
    • Archives
    • Sections
    • Abonnement
    • Alertes
    • Trousse média 2023
    • Avis de décès
  • Visit CMAJ on Facebook
  • Follow CMAJ on Twitter
  • Follow CMAJ on Pinterest
  • Follow CMAJ on Youtube
  • Follow CMAJ on Instagram
Salon

An uncertain death

Graeme Rocker
CMAJ November 09, 2010 182 (16) 1816; DOI: https://doi.org/10.1503/cmaj.101188
Graeme Rocker
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Tables
  • Responses
  • Metrics
  • PDF
Loading

In clinics recently, I sat with an 85-year-old man and his two daughters. Despite my best efforts and experience, I couldn’t be certain about his diagnosis. He had bilateral posterior upper lobe masses and yet looked remarkably well for a man assumed to have metastatic cancer, despite no known primary, negative bronchoscopy and a quite uncharacteristic chest CT scan appearance. We had talked about the uncertainties and the pros and cons of going this route or that to make a ‘definitive’ diagnosis, which could all too easily miss the mark or turn up something incurable. So he declined the percutaneous biopsy and chose instead a gentler route of some prednisone in case there was some variant on bronchiolitis obliterans or other inflammatory component to his illness. Two weeks into this therapy, he felt better and the masses seemed a bit smaller. Through several clinic visits and ongoing diagnostic uncertainty I had given him my best and felt that he knew this.

We hear much about ‘patient-centred care’ and ‘evidence bases’ these days, and while care should be rooted in practices that are evidence-based, it can only flower if the patient’s particulars are included in the evidence base guiding the plan. So this man remained an enigma, but one very much alive, smiling and getting to the mall, a pleasure foregone before the prednisone. His willingness to do without the diagnostic pursuit helped restore the critical balance between uneasiness with uncertainty and the goal of providing care respectful of the individual. He was totally comfortable with his life and with whatever lay ahead.

What lay ahead was a hospital admission as his dyspnea progressed. He remained alert and a joy to chat with to the last. Along the way, exploring the possibility of a move to the Veterans wing, this former chaser of German submarines confessed that, he hadn’t won “World War II single-handedly, but …” He declined again a percutaneous biopsy, a decision that was right on a number of levels, not the least of which was respect for himself. A day after that decision, he slipped away gently into the night. He died in peace without knowing, or needing to know, that those lung masses were indeed cancerous as proven by the subsequent autopsy.

Figure
  • Download figure
  • Open in new tab
  • Download powerpoint

Image courtesy of © 2010 Jupiterimages Corp.

In this era of patient-centred care and the CANMEDS six pillars of wisdom, we seem focused on the “fix” with its seductive illusion of certainty. There is precious little certainty in medicine, though we often delude ourselves to the contrary through an over-reliance on tests, the Internet, hand-held devices or the ever-evolving cottage industry of clinical practice guidelines and meta-analyses. Knowledge of the evidence-base is important, but it does little to explicate the story of the nature and effect of disease in a particular patient, his or her life and family at a particular time. Integrating the science of diagnosis and treatment into the art of clinical medicine must surely begin and end with concern for the care of the human being in front of us where we need to be so much more than highly trained, skilled technicians. In satisfaction surveys, patients and families tell us repeatedly that they want us to master the art of building a caring, attentive relationship so that trust and hope can flourish. 1,2 We need to be willing to sit down, listen to concerns, take time to explain our thinking and get the patient’s take on possible options for moving forward, letting them know that we will do the best we can for them individually. 3 We have to be willing to demonstrate, not just pay lip service to, the notion of care, and this includes having enough humility to say, I can’t figure it out, enough concern to seek out someone who can, and enough integrity to not abandon the patient when no ‘answers’ can be found.

The obituary of our veteran was a wonderful tribute to a family man and chorister, a stalwart of, and much loved and cherished within, his wider community. During his last battle I had no diagnosis or cure to offer him, no fix, but I did what I could to maintain his hope, based on what I had discerned was important to him. Uncertainty being what it is, I did not know for sure whether this was enough. At the reception after the memorial service, I knew it was more than enough. I was kissed by his wife of 57 years and hugged by his daughters. “He thought the world of you,” one of them said, “Because you worked out so quickly who he was.”

Footnotes

  • Previously published at www.cmaj.ca

    Editor’s Note: Signed consent to tell this story was obtained from the patient’s widow.

REFERENCES

  1. 1.↵
    Heyland DK, Dodek P, Rocker G, et al. What matters most in end-of-life care: perceptions of seriously ill patients and their family members. CMAJ 2006;174:627–33.
    OpenUrlAbstract/FREE Full Text
  2. 2.↵
    Heyland DK, Cook DJ, Rocker GM, et al. Defining priorities to improve end of life care in Canada. CMAJ 2010; Oct. 4 [Epub ahead of print].
  3. 3.↵
    Rocker G. You have to try. CMAJ 2010;182:1765–6.
    OpenUrlFREE Full Text
PreviousNext
Back to top

In this issue

Canadian Medical Association Journal: 182 (16)
CMAJ
Vol. 182, Issue 16
9 Nov 2010
  • Table of Contents
  • Index by author

Article tools

Respond to this article
Print
Download PDF
Article Alerts
To sign up for email alerts or to access your current email alerts, enter your email address below:
Email Article

Thank you for your interest in spreading the word on CMAJ.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
An uncertain death
(Your Name) has sent you a message from CMAJ
(Your Name) thought you would like to see the CMAJ web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
An uncertain death
Graeme Rocker
CMAJ Nov 2010, 182 (16) 1816; DOI: 10.1503/cmaj.101188

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
‍ Request Permissions
Share
An uncertain death
Graeme Rocker
CMAJ Nov 2010, 182 (16) 1816; DOI: 10.1503/cmaj.101188
Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like

Jump to section

  • Article
    • Footnotes
    • REFERENCES
  • Figures & Tables
  • Responses
  • Metrics
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • The law and physician-assisted dying
  • Care, compassion, respect
  • Revisiting Rodriguez
Show more Salon

Similar Articles

 

View Latest Classified Ads

Content

  • Current issue
  • Past issues
  • Collections
  • Sections
  • Blog
  • Podcasts
  • Alerts
  • RSS
  • Early releases

Information for

  • Advertisers
  • Authors
  • Reviewers
  • CMA Members
  • CPD credits
  • Media
  • Reprint requests
  • Subscribers

About

  • General Information
  • Journal staff
  • Editorial Board
  • Advisory Panels
  • Governance Council
  • Journal Oversight
  • Careers
  • Contact
  • Copyright and Permissions
CMAJ Group

Copyright 2023, CMA Impact Inc. or its licensors. All rights reserved. ISSN 1488-2329 (e) 0820-3946 (p)

All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association or its subsidiaries.

To receive any of these resources in an accessible format, please contact us at CMAJ Group, 500-1410 Blair Towers Place, Ottawa ON, K1J 9B9; p: 1-888-855-2555; e: cmajgroup@cmaj.ca

CMA Civility, Accessibility, Privacy

 

Powered by HighWire