It’s amazing to me how many physicians don’t realize that their patients are dying. Sometimes I’m in awe and I’m thinking “are you serious?!” Last week we were consulted on a patient because she was 90 with widespread metastatic disease from an unknown primary cancer. The daughter seemed to be on board with getting her home on hospice since the patient repeatedly stated “I want to go home” and she was clearly declining with a poor functional status. The patients son wasn’t on board with stopping all treatments and was encouraged by the primary care physician who stated “If it was my mom, I would continue to treat her and see how things go.” Now this may seem like good advice, but if you all could have seen this poor patient, your heart would have gone out to her and you would have known how I felt. We talked to the daughter during a Goals of Care conversation, since the patients confusion had worsened and she was unable to make decisions for herself, and she stated she had a gut feeling that her mother didn’t have a long time and further chemo was not going to be beneficial. The oncologist told the daughter that further chemo could help the patient improve and live another 6-12 months. The daughter just stated over and over that more treatment didn’t seem to make sense to her. What made it difficult for the daughter was that the primary care doctor recommended more treatment, the oncologist recommended more treatment and her brother was optimistic about more treatment. I was sad inside and was screaming in my head “hurry, please take her home and keep her comfortable before she suffers more in our medical system!” The daughter kept the treatment going based on all the input, despite her gut feeling, and 2 days later the patient began to develop terminal delirium/agitation. She was quiet and peaceful when she was not being touched but as soon as she was touched or spoken to, she began to scream out. This was interpreted by the oncologist as strict pain and he changed the pain regimen I had recommended (the regimen keeping the patient comfortable to this point). There was also an order for further chemo if ok with the daughter!?! I saw the patient that morning and recognized her terminal delirium and noted this in the patients chart and stated that the patient was beginning to actively die. I also called the daughter and informed her. Luckily the daughter opted to refuse the chemo and 24 hours later the patient was made comfort care in the hospital and died 48 hours later. Of course, this isn’t the only time I’ve seen a patient dying and still receiving treatment, but every time it happens I’m still in disbelief. Oncology nurses have shared with me their internal conflict of hanging bags of chemo or sending patients to radiation when they are dying. It’s as if nurses, social workers, chaplains and all other ancillary staff (even the janitor…ok a little sarcasm) can tell when a patient is dying except for physicians. Is it our ultimate fear of failure? Is our minimal time at the bedside? Is part of this financial? Or is it a lack of education and exposure to dying patients. What do you think?