Abstract
The Nocturnists: Uncertainty in Medicine podcast series is a reflection on instances of uncertainty in medicine, from ambiguous diagnoses and complex decision-making to end-of-life care. In the eleventh episode, How We Die, host Dr. Emily Silverman walks us through several stories and a discussion surrounding the uncertainty of death: when it happens, how it happens, and how it is faced in both personal and professional contexts, as we walk ourselves and alongside patients through it.
To begin the episode, Dr. Silverman takes an excerpt from Ursula LeGuin’s The Left Hand of Darkness. In this parable, Lord Berosty is a powerful man; desperate to know the date of his death, he seeks it from the Foretellers. They inform him he will die on the 19th but refuse to specify the month or year. Lord Berosty is unable to live with this partial truth, spiraling into a state of despair that ends in fulfillment of this prophecy.
Like Berosty, many of us, especially in the face of suffering, seek answers. Much of medicine is focused on arriving at a diagnosis; we are trained to identify a condition and treat it, in an approach that often works well. When treatments are no longer working, when cures do not exist, or when patients experience unimaginable pain, we enroll them in clinical trials, we try experimental treatments, and when those do not work, we try our best to provide answers, making projections or estimates of how long someone can live. Uncertainty is pervasive through all of medicine; just as we cannot guarantee an outcome, there are times when what we do know is miniscule in comparison with all we do not.
In the first narration, Dr. Hannah Kirsch shares how her mother called to inform her of her decision to pursue an assisted death. Dr. Kirsch reflects on how she believed herself to be comfortable with death and its ambiguity until she realized she wasn’t. Though she knew not to influence her mother’s decision, she found herself unsure of how she wanted to respond.
In another narration, Dr. Scott Fruhan tells a story of an elderly patient who arrives critically hypotensive, delirious, and likely in ventricular tachycardia at the emergency department with her grandson. Although Dr. Fruhan recognized that delivering an electric shock would resolve her immediate problem, EMS personnel provided him with an ambiguous advance directive, selecting the middle option of selective treatment without “burdensome” measures. Dr. Fruhan spent the next few minutes trying to understand the patient’s directive with her grandson, who had no knowledge of the directive and had been given an impossible task. Eventually, the patient’s grandson decided the best way to honor the patient’s directive was to avoid electric shock and initiate less effective IV medication. However, once additional family members arrived and the patient had been admitted, a hospitalist delivered the shock, and the patient was set to make a recovery. When the hospitalist calls Dr. Fruhan up to the floor, the family is angry because she had not been shocked in the first place, and the grandson gives him a look described as hatred. Dr. Fruhan reflects that “he would have given the patient a shock sooner, but at the time, he was stuck in the uncertainty of it all.” Clinicians are often tasked with asking families to make urgent, difficult decisions wrapped in fear and uncertainty. And yet, this uncertainy burden is one that neither clinician nor family member wants to bear.
This podcast highlights the discomfort we experience with uncertainty; further, it reminds me of the discomfort physicians can experience when debating a consultation for palliative care. Even with clear indications and deep respect for the field, there’s often hesitation. Teams ask, “What will the family think?” or say, “Let’s try one more thing.”
What makes that moment of consulting palliative care so difficult? Beyond prognostic uncertainty, there’s often a deeper personal uncertainty. It can feel like admitting I don’t know what to do. I don’t know how to fix this. But it can also be a quiet gesture of trust, a reach for someone who can help sit with the unknown and help guide patients, their families, and fellow clinicians through it.
As a medical student hearing these stories, I began to understand that the hesitancy to consult palliative care is rarely about the specialty itself. More often, it’s about what it represents. Consulting palliative care can feel like shifting the narrative too soon, before a patient or family is ready. For many physicians, it can feel like a relinquished sense of control, an admittance that all one’s training and skillset can no longer fully serve their patient’s goals. We all struggle with these decisions, not because we don’t care, but because we care deeply. And because we are all human.
Physicians are trained to predict and protect, but, as the episode reminds us, “death is both inevitable and unknowable.” To acknowledge this unknown, to admit “I don’t know,” is something that requires incredible bravery, humility, and an uncommon strength. The strength of palliative care lies in learning to sit with that tension. Not by forcing answers, but by embracing presence. Not by erasing uncertainty, but by validating fear, holding space for grief, and honoring the clarities that do exist.
The Nocturnist’s Uncertainty in Medicine series doesn’t provide us with certainty or answers; it instead reminds us that facing uncertainty with openness, admitting one’s fears, and reaching for help, are not weakness but rather quiet, beautiful, and powerful forms of strength.
Footnotes
Author Disclosure Statement
No competing financial interests exist.