COMMENTARY

'Locker Room' Talk About Death: Time for Oncologists to Stop

Ravi B. Parikh, MD, MPP

Disclosures

September 16, 2021

In a recent inpatient service block, I was seeing patients alongside a resident I had gotten to know well. We were consulted on a patient with metastatic head and neck cancer who had not sought care for over a year.

When the patient presented, his voice was raspy and he could not swallow. He had lost 40 pounds. In addition to his locally advanced disease, his lungs were riddled with metastatic lesions.

When we left the room, the resident and I went to speak to the patient's primary team, and he began to relay our recommendations.

The first words out of his mouth were, "Well, it's pretty clear he's going to die."

The statement took me aback. I wasn't alarmed by the accuracy of what he had said. The patient was obviously not doing well, and he ended up dying soon after this visit.

It was more the abrupt manner in which the resident had spoken about death. The brusque phrasing felt atypical coming from the otherwise gentle-hearted trainee. He wasn't referring to a faceless person. We had just seen the man a few minutes ago and heard his personal struggles. I tried to see if anyone else on the team was caught off-guard, but everyone was taking notes or continuing to listen, seemingly undeterred.

Oncologists' 'Locker Room' Talk

I've noticed that "locker room talk" about death happens often. Phrases like "he's definitely not going to do well" and "his life expectancy is poor" make their way into oncologists' daily language. Thinking back on my own interactions, I realize I am also guilty of discussing death in this way.

And now, with the COVID pandemic forcing most of our tumor boards to go virtual, I find this locker room talk comes even more readily; phrases like "this patient is going to die" are often passed around flippantly, as if saying so will help ease the tension. During these interactions, my colleagues and I rarely acknowledge the seriousness of what a patient death will do to their family and loved ones — or what losing a patient whom we've known for years may do to our own psyche.

This language can even creep into how we speak with patients. We are often taught to offer prognoses coldly, ensuring that patients have a clear sense of how long they have left and to help inform their treatment choices. And yet, this training does not necessarily align with what patients want and need. For instance, in a recent survey of patients with chronic obstructive pulmonary disease, patients consistently rated physicians poorly at discussing prognosis, what dying might be like, as well as spirituality and religion.

But at the same time, these matter-of-fact statements about death probably help protect us. Death is a routine, inevitable part of an oncologist's life, and over time, oncology training and practice hardens us to it. During medical school, I remember that a patient dying would trigger immediate reflection, sadness, and conversation with our peers. Now, unless I know a patient well, I find myself rarely reflecting on the patient behind the facts. This evolution is natural for an oncologist: If you don't develop a tough skin about death, you may become overwhelmed with the frequency of it.

The COVID pandemic has amped our hardness toward death into overdrive. Whether we are in the intensive care unit or simply viewing death rates during the most recent COVID Delta wave, many of us cope by disassociating a face from a name.

Making Time for Reflection

But taking time to reflect can be therapeutic.

I recently referred a patient with metastatic prostate cancer for a phase 1 trial at an outside institution. He was one of the first patients in my genitourinary malignancies clinic when I started as an attending. The patient had progressed through several lines of therapy and was being referred for an investigational phase 1 therapy. We had discussed hospice referral, and the patient was ready for it if this therapy didn't work out.

I did not see or hear from the man while he was on the trial. A few months later, however, the principal investigator of the trial called me to let me know the patient had progressed through the agent, suffering from significant urinary obstruction, and he was on hospice. "Unfortunately," the investigator told me, "he's not going to live much longer."

When I checked in with the hospice, the patient had died.

I was surprised again at how matter-of-fact the discussion of death had been. But I was even more surprised by my own reaction. Despite the relationship I had formed with the patient, I did not feel much when I heard he had died. I didn't have time to process the news in the moment. It was time to move on to the next patient.

It was only later, when I called the patient's family, that I allowed my emotions to flood in. I told his family how grateful I was to know him, how strong he'd been. The patient's family and I talked about the human, not his passing. It felt good.

Abandoning Locker Room Talk

So how do we change how we talk about death? I don't think the answer is massive educational programs or passing responsibility for advance care planning onto palliative care specialists. The change needs to be driven by individual oncologists. We can call out discussions of death that make us uncomfortable, gently reminding each other that we're talking about a human life.

We can learn from our palliative care colleagues; their conversations about death routinely include a patient's support system and personal stories. Palliative care doctors always refer to the patient by name, which helps humanize the person behind the chart.

We can emphasize a feeling of hope, a sentiment that may also be therapeutic to our patients. Even when a patient is dying, there is always something to be done. We can comfort their family, explaining what brought us to this point and how sorry we are that this is happening. We can provide options for symptom control and help patients manage those symptoms.

And we can allow ourselves to talk about how much a death affects us. We can acknowledge how much it sucks that a patient is going to die, how challenging that will be to his/her family, and how we wish it could have ended differently.

Subtle changes like these will improve our own ability to process and discuss death and will ultimately lead to better relationships with our patients. But it starts with eliminating the "locker room talk" of how we discuss death.

Ravi B. Parikh, MD, MPP, is a medical oncologist and faculty member at the University of Pennsylvania and the Philadelphia VA Medical Center, an adjunct fellow at the Leonard Davis Institute of Health Economics, and senior clinical advisor at the Coalition to Transform Advanced Care (C-TAC). His research and writing focus on policy and innovation in cancer care, with specific interests in advanced illness and predictive analytics.

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