n the 2004 country music chart-topper “Live Like You Were Dying,” the singer Tim McGraw describes one man’s reaction to learning he had a incurable disease:
“I went skydiving. I went Rocky Mountain climbing. I went 2.7 seconds on a bull named Fu Manchu.”
The idea that someone with a terminal diagnosis might throw caution to the wind is seductive — and, according to behavioral science, it’s also a quite reasonable response under the circumstances.
But circumstances change, and so do people faced with end-of-life decisions, especially as the weight of bad news starts to sink in. That’s something for doctors and patients to keep in mind as they consider different treatment options when the end is near.
All medical decisions come with a degree of risk. But people tend to judge the amount of risk differently based on their vantage point.
If you just found out you had metastatic brain cancer, you might ask for an unproven therapy, ignoring the potential for side effects and thinking only about beating the odds. Let the information sink in for a while, though, and standard care might start to make more sense.
These sorts of decisions are, of course, personal — but a person’s aversion to risk can change as their new realities set in.
This idea that people make different choices based on their reference point, rather than on the final outcome, is known in behavioral economics as prospect theory.
To demonstrate the theory, Duke University’s Emma Rasiel often uses a hypothetical situation where someone has experienced a tremendous loss: their freedom. The question is how much risk that person might be willing to absorb to regain it.
“Let’s say I just kidnapped you, and I’m bizarre,” Rasiel said. “I offer you a deal, where you can either pay me $10,000 to let you go, or we can toss a coin: If it’s heads, you pay me $20,000, and if it’s tails, you go free.”
Ninety percent of people would choose the coin flip, even though there’s a 50:50 chance they’ll end up having to buy their freedom for $20,000.
But in situations where a person experiences a sudden improvement in their status quo, they grow more risk-averse. “If I offered you a choice between a sure $10,000, versus a coin flip where you could get no money if it’s heads, or $20,000 if it’s tails, most people will just take the $10,000.”
The passage of time can, however, affect one’s appetite for risk, especially when the person’s circumstances have worsened. In such situations, Rasiel said, once someone adjusts to their new baseline, they tend to be less willing to take on risk.
Medical professionals can use this insight from economic theory to inform their bedside manner.
When delivering a life-limiting diagnosis, doctors must weigh how much information to deliver right away, and how many decisions to foist upon their patients all at once. Given the shock of such news, many cancer patients don’t absorb the reality of their situation, and often don’t make the most effective treatment decisions.
A good oncologist or primary doctor will help a patient navigate such obstacles. But millions of Americans don’t have doctors they know and trust. For them, a terminal diagnosis could be delivered by an emergency room physician in the last hour of an 18-hour shift, with a dozen more patients waiting for help.
There is one significant unanswered question in all this — namely, how much time does it take the average person to adjust to the new normal of a terminal diagnosis? Rasiel said that, to her knowledge, researchers have yet to study that element.
“That timeline becomes very important, and no doubt different people adapt at different speeds,” she said. “It might take six months to a year to fully adapt.”
Patients don’t have the luxury of waiting that long to act. But future research into the issue could help doctors and patients more effectively collaborate on perhaps the most important decision any person might face late in life.
In the meantime, throwing caution to the wind is, perhaps, something best left for country rockers.