When death comes knocking
Greenville News

After eating her ham and cheese sandwich and sipping a cup of tea, Elizabeth Knecht nestled into a couch, a white cardigan covering the shoulders of her 85-pound frame.

A plaid blanket was draped over her legs attacked by cancer.

Her son-in-law, Ray Washeleski, softly shut the front door of his Greer home to block the bright sunshine that hurts her eyes. Spring is near and buds are forming on the trees in the Terrace Gardens neighborhood.

By fall, when those leaves have turned brown, 88-year-old Knecht will be gone.

She doesn't know exactly when she'll die -- she doesn't want to know -- but she wouldn't be receiving hospice care unless she had less than six months to live. Hospice care nurse Cara Roberts has already been visiting for a month.

Doctors and hospice workers say it's important for terminally ill patients to receive hospice care for as long as possible in order for nurses to monitor how a patient responds to pain and to teach family members the symptoms and signs of impending death.

But when it comes to estimating how long cancer victims and other terminally ill patients will survive, doctors are often dead wrong.

Their predictions are so off that, on average, people told they have five months to live will probably die in one, according to a study recently published in the British Medical Journal. Doctors were right just 20 percent of the time.

The problem is that there are no formulas or rules.

"You can't read it in a textbook," said Dr. Gregory Formanek, a cancer doctor with the Greenville Hospital System. "There have been patients who I thought were going to die within a couple days who were still alive three months later."

Mostly, it's unintentional optimism that leads doctors to overestimate a patient's survival time. Formanek said he thinks doctors, unwilling to accept their own mortality, might view a patient's death as a failure.

"You are taught that your job is to keep people alive and keep them going and not let them die," he said.

But when it comes to cancer, it's not always possible to keep people alive, and about 10 times a month Formanek has to tell someone how long they've got left.

"I think the physician owes the patient and the family honest facts about when that is going to happen so they can prepare for it," he said.

Sometimes, doctors don't want patients to lose hope, said Dr. Jeanette Wilcox, a radiation oncologist and medical director of hospice care for the Greenville Hospital System.

"We don't want the patient to sense that we think they might be getting toward the end because they might feel abandoned," she said.

Dr. Kim Gococo, an oncologist with the Cancer Centers of the Carolinas, said doctors seldom underestimate how long a patient has left to live.

"Most of the time the doctor estimates months and it will actually be weeks," he said.

Upstate physicians say that undue optimism -- whether intentional or not -- can delay the patient's referral to a hospice.

"It's a real challenge for us," Wilcox said. "The hospice patients benefit most when they are in hospice for several months."

Many times, hospice care workers don't see a patient until a few days, or even 24 hours, before they die.

"That can be traumatic for a family," said Roberts, who works for the Greenville Hospital System hospice and checks on Knecht once a week.

In the latest study, 343 doctors treating 486 terminally ill patients in Chicago overestimated the time they had left to live in 63 percent of the cases.

Surprisingly, the better the physician knew the patient, the more likely he or she was to err. Consequently, the study said, a second opinion from a more detached source may be valuable.

But Gococo said it isn't a doctor's job to predict how much time someone has left.

"I think we are supposed to care and help and inform some, but I think life and death is something we cannot control," he said.

That's exactly how Knecht views her impending death.

"I really don't worry about it," she said as oxygen flowed into her nose through a long, plastic tube winding across the living room floor.

Her daughter, Geraldine, and son-in-law welcomed Elizabeth into their home on New Year's Day 1999. The cancer that took her left breast crept into nearly every part of her body and forced her from her Fair Lawn, N.J., home where she had lived for 60 years.

That was harder to deal with than death, she said.

For now, her mind is often filled with thoughts of food -- especially candy, ice cream or anything sweet.

Last week, Washeleski made an emergency trip to the grocery store. His mother-in-law had a sudden craving for sardines.

"I'm still alive and kicking," she said with a chuckle.