How Long Do I Have Left, Doc?

My doctor gave me six months to live, but when I couldn't pay the bill he gave me six months more. - Walter Mathau

Before I became a doctor I used to wonder how accurate the medical profession is at determining how long you have left to live.  Now that I am a trained and experienced physician, I wonder even more.

I’m sorry to have to break the news to you, but your illness is fatal.  You have six months to live.

Why is it always six months?  Why not 4 months, or 7 months, or 26 days?

I’ll confess that I never tell patients how much longer they have on this earth.  Simply put, I don’t have a clue how to determine this and I have a suspicion that most doctors don’t, either.

I was educated quite early in my career that my attempts at setting a date for a patient’s demise were as reliable as predicting spring weather in the Midwest.  During my residency I admitted a comatose man to the medical unit with the diagnosis of liver cirrhosis and encephalopathy.  When the liver stops doing its job (mainly, to filter toxins from the blood) the body begins to simmer in its own metabolic waste, turning the skin and eyes yellow (jaundice).  This patient in particular had the worst blood levels I’d ever seen and his skin practically glowed in the dark.  I pulled the family aside and gave them the bad news that the patient had days—perhaps only hours—to live.  Showing no emotion they curtly discounted my prediction: “He won’t die.  He does this every time and always pulls through.”  No, I said, this time it’s different.  He won’t survive.

You can guess how this story ended.  The patient mounted a miraculous recovery and walked out of the hospital a week later, ready to hit the booze again and test the function of his half-dozen remaining liver cells.  From that moment on I stopped dogmatically declaring any sort of prediction on life expectancy.

If you do an internet search on “six months to live” it’ll take you only seconds (actually, 0.22 seconds according to Google) to come up with 481 million entries on the subject.  Granted, most are not stories of dying patients, but many are.

Sometimes doctors underestimate a person’s viability.  Abdelbaset Ali Mohmed Al Megrahi, the former Libyan intelligence officer who was found guilty in the bombing of Pan Am flight 103 over Lockerbie, Scotland in 1988, was freed from prison after doctors determined that prostate cancer left him only 3 months to live.  That was 18 months ago.  He’s currently residing—very much alive—in a villa in Tripoli.

At the other end of the spectrum is Susan Atkins, who gained infamy for her complicity in the 1969 slayings as part of Charles Manson’s group.  In June, 2009, her doctors diagnosed her with terminal cancer and suggested she had 6 months left to live.  She was dead only 3 months later.

I found the story of one patient in the news who sold everything he owned in preparation for the afterlife once his doctors told him he had only months left.  Three months later the “cancer” they had seen in his liver turned out to be nothing more than benign spots.  Lawsuits are pending.

Even the stories that are clearly clever inventions by tawdry supermarket tabloids reinforce the concept of doctorly divinations, even when the headlines are nothing more than wild speculation. The Globe reported in August that our former president is on his deathbed, ravaged by heart disease and Parkinson’s, and will be gone by springtime: “Bill Clinton: Six Months To Live.”

In an attempt to get a better handle on this issue I spoke with someone I consider a true expert on the matter.  Dr. Yungpo Bernard Su is an Omaha-based medical oncologist who treats patients with cancer and therefore wrestles frequently with the issue of predicting life expectancy.  Dr. Su started by expressing his wariness of the language commonly used when discussing the issue: “I don’t like the phrase ‘my doctor gave me 6 months to live.’  The use of the word ‘gave’ implies that the doctor has the power to bestow something rather than simply doing his or her best to predict it.  Doctors can’t give anything except their best estimate.”

Dr. Su’s approach is marked by honesty and compassionate directness.  He agrees that we don’t typically do a very good job at predicting a timetable and confirmed that there is no magic algorithm that he uses to come up with a life expectancy.  Dr. Su typically starts with widely available epidemiological data that provides an expected lifespan for a population of patients with any particular form of cancer.  He draws from the results of past clinical trials that have reported the average survival time for a group of patients with the same disease and stage of treatment.  Dr. Su then tries to apply these data to the individual patient—taking into account age, nutritional status, coexisting medical illnesses—in an attempt to find the most accurate range for the individual patient.

It’s at that point that Dr. Su has an open discussion with the patient about how he tries to determine the details of his prognosis and how inaccurate it can be for any one particular person.  He is careful to explain that an estimate based on a statistical average will be correct only for those patients who are most “average.”

In my discussion with Dr. Su we came to the conclusion that the best approach is to pull back the curtain (to employ a metaphor from The Wizard of Oz) and allow the patient to see the inner workings of how such predictions are made.  Hopefully, armed with the understanding that modern medicine’s forecasts are sketchy at best, the patient comes away knowing that Dr. Su is no wizard who is giving them anything except the promise of excellent care and the confirmation that he’ll stick with the patient throughout the course of the illness, whether it be 6 months or 6 years.

I like Dr. Su’s honest and forthright approach.  Still, I can appreciate a person’s desire to know in detail how long they have left without invoking estimates, averages, and probabilities.  Will I live long enough to see my daughter’s wedding?  Should my husband and I take the trip we’ve always dreamed of?  How long will my family and I have to suffer through this?

If I had a terminal illness there would be some part of me that would welcome a doctor’s pronouncement of my longevity even though I know how unreliable such estimates can be.  I think this is why the concept of “six months to live” has become so popular in our culture—we all want to believe that if doctors can’t cure us they can at least “give us” the date of our demise.

And then, of course, we try to hang on a little longer just so we can prove them wrong.