It’s a favorite quip of mine, but usually elicits little more than eye rolls. I ask medical trainees if they enjoy reading fiction, and if they reply “yes” then I pass over the medical chart. It is not only medicine’s dirty secret it may be our profession’s version of a famous Indian Parable. Various blind men touch different parts of an elephant and come to very different conclusions. One feels the elephant’s side and concludes it must be a wall, one its tusk and assumes a spear, and one its tail and assumes a snake. The moral is that we all tend to project our experience as if we possess the whole truth, and nothing but the truth. This brings me back to medical charting and explains why two perfectly capable doctors can have three plausible opinions. It is why it’s darn tough to know exactly what to write on a death certificate. It’s not entirely fiction, but nor is it unalloyed fact.
The documentation of death, and the role of medical examiners and coroners differs slightly from jurisdiction to jurisdiction. However, one thing hammered into each medical student is that you can’t write “old age” as a cause of death: no ifs, ands, or buts. Thirty years into my medical dotage and I believe this is unfair. Sure, there are certainly 80-year-old folks who can shame 50-year-olds with their fitness. However, the number one cause of in-hospital death is increasingly “frailty”. Frailty is not exactly the same as old age, but is associated with how many sands have passed through your hourglass. To the white coat brigade “frailty” is not a pejorative term, but rather means “cumulative illnesses or insults from which the patient does not bounce back”. Like many of our words it sounds terribly clever when, in fact, it’s still vague. Families are as close to the bullseye when they combine words like “straw” “camel” “broke” and “back”.
In the intensive care unit, we cause similar consternation if we write “multisystem organ failure”, on a death certificate, although it is similarly on point. How else to summarize the process of wheeling in every machine and leveraging every pill and potion, only to watch one organ fail after the next. In this domino procession, the downstream organ cannot do the work of the one upstream. Eventually none pick up the slack, and it’s time to wheel the machines out of the room. The heart is usually the last organ to go, but that does not mean the patient died of cardiac arrest, or because nobody performed chest compressions. Despite all our bombast, it is easier to write what you died with, but difficult to divine what you died of.
While I am busy busting medical myths let me get this one off my chest, and heart, and kidneys. Strictly speaking nobody dies of cancer, but rather because of the chaos that cancer creates. It can rubbish the immune system and block every orifice, and hence infections occur. It can eviscerate the bone marrow and hence we can bleed to death. On the other hand, it can also clot the blood and cease the circulation. Doctors often write cancer as a cause of death, but do understand it includes a degree of wet finger held in the wind. It is also mandatory in Canada that the death certificate be completed in black ink. Perhaps this is to make the uncertain seem less so. Regardless, if ink colour doesn’t increase precision then nor will electronic charting.
With the risk of being cheeky: death rates are 100% and holding steady. In other words, something will eventually get you and me. Therefore, it is not necessarily a tragedy if you live long enough to get a disease associated with old age. While sharing awkward truths, we will never eliminate cancer; we merely strive to make it a chronic disease. For example, once cancer can’t be found for five years we claim a cure. This deserves celebration, as does every day on this planet, but let me slightly spoil the party. Live long enough and you, and I, will get cancer or a reoccurrence. For example, autopsies show that all men will eventually get prostate cancer; fortunately, most will die of something else.
“So what?” you might ask: just write something reasonable and move right along or call the medical examiner. The issue is that what we medical people write has financial and legal consequences. Your cause of death will be a statistic and statistics inform what gets funded. Just as pharma pays to have their products placed on TV medical dramas interest groups are apparently paying to have their disease featured because placement equals donation. In contrast, in real life, family members used to ask for the word AIDS to be left out because of the associated stigma. If we write “smoking” then it sounds like somebody’s fault, whereas lung tumor sounds like more an act of God. “Got drunk and drove into a school bus” has legal implications while “motor vehicle crash” sounds relatively anodyne. The word “suicide” or “overdose” can affect whether life insurance is paid out, and the word “aneurysm” can affect future generations likelihood of securing coverage.
Back to autopsies for a moment. The idea is noble: to reassure the medical team and the family that they did all they could, and to help the next patient. In practice, far fewer are done these days, and this is not necessarily wrong. Firstly with modern medical imaging and laboratory testing we have usually probed the insides for all they reveal. Any additional insights come with delays which can stall rather than aid closure, and a mental image that is distressing to many loved ones. To paraphrase several families when I have broached the topic “if it’ll bring her back then sure, but otherwise she been interfered with enough”. Which brings me back to the Indian Parable. When it comes to death as well as life, it appears that doctors, lawyers, insurance companies and families may also be feeling different parts of a beast. Regardless, death will always be an elephant in the room. You can trust me about that.
Peter Brindley, professor in the department of critical care medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, Canada. He is on Twitter @docpgb
Competing interests: None declared.