Withholding Tragic Knowledge May Lead to a Tragic Death:A Palliative Care Perspective

Irene Ying

� Societe Internationale de Chirurgie 2014

I read with interest the article by Suri et al. [1] on the

harms and benefits of sharing ‘‘tragic knowledge’’ with

patients. However, I want to clarify that there have been

no good studies to indicate that unrealistically optimistic

patients benefit at the end of life. In fact, a study looking

at patients with advanced cancer found that those who

were overly optimistic were more likely to receive

aggressive treatments and die while on a ventilator—all

without survival benefit [2]. Studies that have pointed to

the psychological benefits of unrealistic optimism in

cancer patients are flawed because they are overwhelm-

ingly cross-sectional in their design and do not take into

account the emotional distress of patients and families

when death is imminent.

As a palliative care physician, I have seen this last-

minute realization be accompanied by the awareness that

there is no longer the opportunity to put affairs in order

or to engage in meaningful legacy work. Take the

40-year-old woman with widely metastatic breast cancer

who refuses to acknowledge that she only has weeks to

live. She does not talk to her children about why she is

becoming frailer by the day. Some may argue that this

avoidance is allowing her to live more fully in the

moment with her children. However, her last days may

be filled with fear and regret. Not only is this difficult

for the patient, but the last memories her family have of

her will be marred by her existential distress. This is

important to acknowledge for two reasons. First, it

emphasizes the need to move beyond the traditional

dyadic physician–patient model of medicine. When

appealing to the ethical principles of beneficence and

non-maleficence, we need to shift to a more relational

model of care—taking into the consideration the well-

being of not only the patients, but also of those closest to

them. Second, recent findings looking at what makes us

happy have revealed that there is a marked difference

between our experiences and our memory. As noted by

the Nobel Prize-winning psychologist Daniel Kahneman

in his 2010 TED talk [3], there is a ‘‘difference between

being happy in [one’s] life and being happy about

[one’s] life.’’ A so-called ‘bad death’ can negate all the

good that death avoidance provided, but good prognosis

and goals-of-care discussions can help people shift from

the former to the latter.

However, until surgical curriculums view these dis-

cussions as a skill that is as important to teach and

evaluate as the dissection of anatomical planes, physicians

will continue to cause iatrogenic harm through the

omission or ‘mis-sharing’ of information with patients.

The challenge in teaching such a skill is that it cannot be

approached in a prescriptive way, but rather must be

viewed as a delicate dance—ever evolving and often

times circuitous. But learn it we must, because, as the

anti-hero surgeon of Abraham Verghese’s novel Cutting

for Stone [4] so adroitly put it, ‘‘What treatment in an

emergency is administered by ear?’’ The answer is

‘‘Words of comfort.’’

I. Ying (&)

Division of Palliative Care, University of Toronto, Toronto, ON,

Canada

e-mail: irene.ying@utoronto.ca

I. Ying

Department of Family and Community Medicine, Sunnybrook

Health Sciences Centre, 2075 Bayview Ave, H-353, Toronto,

ON M4N 3M5, Canada

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World J Surg

DOI 10.1007/s00268-014-2676-y

References

1. Suri M, McKneally M, Devon K (2014) Tragic knowledge: truth

telling and the maintenance of hope in surgery. World J Surg.

doi:10.1007/s00268-014-2566-3

2. Weeks JC, Cook EF, O’day SJ et al (1998) Relationship between

cancer patients’ predictions of prognosis and their treatment

preferences. JAMA 279:1709–1714

3. Kahneman D (2010) Daniel Kahneman: the riddle of experience

vs. memory [video file]. http://www.ted.com/talks/daniel_kahne

man_the_riddle_of_experience_vs_memory. Accessed 2 May

2014

4. Verghese A (2010) Cutting for stone. Vintage Books, New York

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