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Death Foretold: Prophecy and Prognosis in Medical Care

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ISBN-13: 978-0226104713
ISBN-10: 0226104710
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Editorial Reviews

From Library Journal

In this important book on the issue of medical prognostication, Christakis explains that even though doctors commonly encounter situations that require a prognostic diagnosis, they feel poorly prepared, find it stressful, and believe that patients might judge them adversely in the face of prognostic errors. Drawing on his own knowledge of bioethics, his experience as a sociologist, and his work as a physician, Christakis has taken on the task of interviewing his colleagues, searching medical school curricula, gathering medical texts, and creating his own quantitative research to provide readers with a comprehensive consideration of this murky area of medical practice. This treatment takes us from a history of the social construction of prognosis, to an examination of the need for it, through the perils of accountability, and concludes with a "clarion call" for the duty of the healthcare industry (especially physicians) to find better ways to prognosticate. Highly recommended for everyone from patients wrestling with their personal prognosis to any medical practitioner touched by this bioethical dilemma. Especially suited for medical school libraries.ARebecca Cress-Ingebo, Wright State Univ. Libs., Dayton
Copyright 1999 Reed Business Information, Inc. --This text refers to the Hardcover edition.

From The New England Journal of Medicine

Will my congestive heart failure ever go away?" "Just what will the diabetes do to me?" "Does this cancer mean I'm going to die?"

These questions demand answers that will shape how patients relate to their illnesses. Prognosis affects their lifestyle choices, health care decisions, and overall outlook. Yet, many physicians dread responding to such questions. What underlies this fear, and what are its consequences?

It seems natural that we should wish to avoid sharing bad news. Offering a grim prognosis forces us as physicians to deal with a patient's grief and confront our own sense of futility. Furthermore, patients may not wish to hear what we have to tell them. Yet, even when the outlook is optimistic, discussing an uncertain future makes us cautious. There is something deeper here.

In Death Foretold: Prophecy and Prognosis in Medical Care, Nicholas Christakis proposes that prognostication evokes awe and mystery because it casts the physician in the role of prophet. Many physicians are overwhelmed by the power and responsibility of such a role and, like Jonah boarding the ship to Tarshish, attempt to flee altogether. Yet, Christakis concludes, physicians -- like prophets -- have a moral duty to predict the future and must find appropriate ways to do so.

His argument is sophisticated, extraordinarily well supported, and compelling. The book is based on his own extensive research on the attitudes of physicians toward prognosis and a thorough review of the relevant medical and sociological literature. Christakis begins by describing what he calls the "ellipsis of prognosis" in modern medical thought. Prognosis, diagnosis, and therapy are the primary functions of medicine, yet among these three, prognosis receives the least amount of attention. Although implicit in nearly all diagnostic and therapeutic decisions, prognosis per se is neglected, avoided, and even despised. Christakis points out the absence of discussion of prognosis in textbooks, medical education, and encounters with patients.

Christakis then presents data to show that physicians frequently make errors in prognosis and that such errors are not random. Physicians convey an optimistic bias when discussing prognoses with each other and when sharing them with patients and families. They are likely to overestimate survival and future quality of life. The most fascinating data from Christakis's interviews and surveys suggest that physicians believe in the self-fulfilling prophecy -- as a group, physicians believe that predicting outcomes may actually cause them to happen.

There may be logical explanations for this belief. For example, after hearing their prognosis, patients may change their behavior with respect to health and thus affect their own outcomes. However, many physicians believe that the effect of the self-fulfilling prophecy is mediated by forces beyond human control. They have internalized the sort of magical thinking we often ascribe only to patients. This has important implications. Physicians, acting in what they see to be the patient's best interests, will avoid the delivery of bad news or present prognoses in an unduly favorable light. The self-fulfilling prophecy leads to what Christakis calls the "ritualization of optimism" in medical practice.

The powerful metaphor of physician as prophet complements a view of prognosis as "meaningful, mysterious, and influential." Prophets, through divine inspiration, foretell the future and yet are frequently unpopular. They are obligated to continue their prophecies for the good of those who prefer not to hear the message. These attributes of prognosis convey strong moral overtones and motivate Christakis to conclude that, despite the problems, physicians have a duty to prognosticate. The book closes with recommendations for clinical education and practice that can help physicians fulfill this obligation.

This exceptionally well written book is spiced with quotations from interviews with physicians and audiotaped clinical encounters that highlight the painful issues raised by the discussion of prognosis. Clinicians will find these voices of medicine authentic and engaging. Trained as both a physician and a sociologist, Christakis speaks directly to doctors and presents social theory without resorting to jargon.

This book is comprehensive, although two areas could have received greater attention. First, Christakis acknowledges that he has focused solely on the attitudes of physicians. This leaves the reader wondering about what patients expect from conversations about prognosis. How do patients define hope in the face of an uncertain future, and what role do physicians have in maintaining their hope? How do we respond to patients who request an optimistic bias? We must answer these questions before articulating a comprehensive approach to the discussion of prognosis. Second, the author writes that "prognosis gives diagnosis its affective component, striking fear in patients and physicians alike." Yet, he does not fully probe the implications of this statement. Requests for information by patients, phrased in the form of questions such as "Am I going to die?" may be expressions of fear rather than true inquiries. If one does not recognize and manage skillfully the emotion underlying the question, then the honest prognostication Christakis hopes physicians will learn to convey will not be heard. Managing emotions and prognosticating are interdependent and require equal attention.

This superb book offers the most scholarly analysis ever written of prognosis, and I recommend it highly to anyone interested in the doctor-patient relationship. Prognostication is one of the most important and difficult tasks physicians perform. Informed by his own practice, Christakis has tremendous compassion for the struggle of the individual physician. He argues forcefully that the profession must take responsibility for the current widespread avoidance of prognosis and change the present culture. This prophet is one whose advice we would do well to heed.

Reviewed by James Tulsky, M.D.
Copyright © 2000 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS. --This text refers to the Hardcover edition.

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Product Details

  • Series: Prophecy and Prognosis in Medical Care
  • Paperback: 374 pages
  • Publisher: University Of Chicago Press (April 1, 2001)
  • Language: English
  • ISBN-10: 0226104710
  • ISBN-13: 978-0226104713
  • Product Dimensions: 6 x 1 x 9 inches
  • Shipping Weight: 13.6 ounces (View shipping rates and policies)
  • Average Customer Review: 5.0 out of 5 stars  See all reviews (4 customer reviews)
  • Amazon Best Sellers Rank: #921,204 in Books (See Top 100 in Books)

More About the Author

Nicholas A. Christakis is a physician and social scientist, and a Professor in the Departments of Medicine, Health Care Policy, and Sociology at Harvard University. For more than ten years, along with his buddy, James Fowler, he has been obsessed with how social networks form and how they function.

Prior to this obsession, Christakis had another one, namely, to improve the care of the dying in our society. As a hospice doctor and researcher, he studied ways to improve the care of the terminally ill, and he advocated for their interests. In fact, it was his research into the "widower effect" (or "dying of a broken heart"), a topic that has concerned scientists for over 150 years, that first kindled his interest in social networks. If the death of one spouse can increase the risk of death of the other, than surely other things can also spread between pairs of people, and between larger numbers of connected human beings, he thought.

Dr. Christakis' lab at Harvard currently studies the mathematical, biological, and social underpinnings of social networks.

Christakis was elected to the Institute of Medicine of the National Academy of Sciences in 2006, and he was named by Time magazine to their annual list of the 100 most influential people in the world in 2009.

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13 of 13 people found the following review helpful By A Customer on January 27, 2000
Format: Hardcover
Death Foretold is an exceptional book. Effortlessly blending history, sociology and clinical acumen, it tells the story of how and why doctors (sometimes) avoid answering the one question their patients really need the answer to: "So what does this mean for me?". It marshalls an impressive array of data, from wonderfully human qualitative interviews with physicians, to rigorously executed quantitative experiments and surveys. All is explained in an elegant and eminently readable voice deeply sympathetic to the patients undergoing awful disease, the families caring for them, and the physicians charged with helping. This is a book that any one training (or trained) in the healing arts must read; but it is also a rare and wonderful chance for those who may one day be patients nearing death to gain some insight into what that experience is like -- and the rich possibilities it could also have.
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7 of 7 people found the following review helpful By A Customer on March 2, 2000
Format: Hardcover
Nicholas Christakis offers insightful research and well written conclusions in Death Foretold: Prophecy and Prognosis in Medical Care. The ability for physicians to determine with accuracy the end of life offers hope of a better end for patients and families. When medical schools address this overlooked subject, patients will suffer less, be able to plan remaining time wisely and receive appropriate Hopsice and other care. Dr. Christakis is really writing about living well - even if it is the last living the patient does. A superb book for the lay population, as well as medical community - one that hopefully will be heeded by medical school faculties as curriculum is being reviewed.
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5 of 5 people found the following review helpful By Midwest Book Review on March 3, 2000
Format: Hardcover
Death Foretold focuses on the doctor's prognosis in medicine, exploring how this prognosis is made and how it's presented to patients. Interviews, surveys and the author's own experience considers the nature of medical prognosis, common errors, and how they're presented and interpreted on all sides. An essential probe of a little-covered subject.
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9 of 11 people found the following review helpful By A Customer on January 28, 2000
Format: Hardcover
Near the end of life most of us confront death with great fear. Although physicians are often shepherding us and our families through this critical time in our lives, it is often the case that their efforts fail -- leaving us to anticipate a miracle, and often shocking the surviving relatives when death finally does arrive. I never realized it before reading this book, but physicians often fail us at one of the most critical and vulnerable times of our lives, at the end. Dr. Christakis has illuminated the problems associated with physician's who are unable or unwilling to prognosticate death -- revealing a shortcoming that needs attention. This book should certainly be read by physicians, but I also recommend it for the general public. Dr. Christakis deserves credit for shedding light on a topic that too few physicians are willing to talk about.
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