A physician’s regret for not broaching end of life questions


As a practicing geriatric physician, I realize I owe my patients an apology.

I am sorry, Mr. Smith, for the current crisis you and your family are facing today. While you are just trying to maintain your independence and your dignity, living with complicated medical conditions, your family has been concerned and scared on how to provide the best care for you. The fact that you have not had a physician guide and prepare you for aging years has led to your current crisis. As your physician, I take part of the blame for the situation that both you and your family face in this stage of your life.

I am sorry, Mr. Smith, for not recognizing this sooner. You have seen many other health care providers over the years trying to treat and maintain your medical problems, prescribing multiple medications, with sometimes unclear goals to achieve. So how is it that there has been no time to help prepare you and your family for your aging? How is it that you, my dear patient, who is a father living with advanced heart disease and having difficulty walking, have never had me or any other provider spend time with you discussing your goals of care? I never took the time to ask you what you really wanted for yourself for your health care needs.

I am sorry, Mr. Smith, for putting your family in the situation of uncertain decisions and taking away your autonomy. Because I never took the time to actually ask you about your future care, your family will answer for you. I never asked how you defined a good quality of life – what living means to you. Do you want to age and die in the home where you have spent the majority of your life raising your family? Would you want your life to exist on machines or tubes, or would you rather focus on a more comfortable, natural pathway? Would living in a nursing home be acceptable if you could no longer live alone? If not, are you financially prepared to pay for help to keep you in your home or have you discussed with your family about their being your caregivers?

I am sorry, Mr. Smith, for expecting you to bring up these difficult conversations yourself to me and to your family. How did I expect you to bring up conversations about your medical care when you may not have had any experience navigating this complicated and confusing health care system? And yet, I realize, you actually have brought up these issues to me.

My first concern was always dealing with your physical concerns that would prolong your life as long as possible – managing your blood pressure, your diabetes, your cholesterol, even encouraging you to consider some extraordinary measures to get you “well” again. In actuality, you looked at the situation much differently. Your primary concern was to make your years as enjoyable and comfortable as possible, without worrying so much about prolonging your life if it meant a significant altered quality of life. All you know is that you worked hard your whole life, served your community and country, focused on raising your family. You never thought twice that your health insurance, Medicare or other community resources would not cover costs for your future aging and health care needs. All your family wanted to do was to take care of you based on your wishes – which were never clear because we never spoke about them. If only I had asked you sooner.

Mr. Smith, I cannot go back in time to the moments where you occasionally questioned my medical advice. In actuality, that was your way of telling me to ask you about what you wanted for your own well-being. I cannot go back and spend more time with your family who needed the reassurance, validation and support to care for you so you could remain and age at home.

But it’s not too late now. I am here now listening to you, my dear Mr. Smith.

Christine Khandelwal, DO, lives in Raleigh.