The Farewell (2019): Not Telling the Patient

Billi's grandmother in Changchun is found to have stage IV lung cancer. She is given a short time to live. The family decides she will not be told. A cousin's wedding is hurried forward so everyone can gather and say goodbye without her knowing why.

Billi was raised in the United States and cannot accept it. She is also the person standing between her grandmother and the doctors. Spoilers throughout.

The film's central argument is not invented. NCI's summary on communication in cancer care has a whole section on demographic and cultural considerations. It names language, family structure and religion as things that shape what people want said, and by whom.

It also flags a risk in the other direction. NCI describes a shift away from cultural competence, which asks clinicians to learn the beliefs of particular groups. The idea replacing it is cultural humility. That means lifelong self-critique, and redressing the power imbalance between patient and physician. The film sits exactly on that line. It refuses to turn the family's choice into a lesson.

For viewers in the United States, one thing is settled. MedlinePlus states it plainly. By law, health care providers must explain a person's health condition and treatment choices to them. That explanation is what informed consent means.

There is real room inside the rule. A patient can say they would rather not hear a prognosis. Or that a named relative should be told first. Either preference belongs in the notes. What cannot happen is a family deciding it on an adult's behalf. How much detail a person wants varies enormously, which is the subject of this page on prognosis information.

The quiet clinical error in the film is one almost nobody names. The family is doing the translating.

NCI's guidance is direct. Health care organizations should provide language help for any patient who speaks a different language from their clinician, at no cost to the patient. Clinicians should not use a patient's family or friends to interpret. NCI gives two reasons. Relatives may not pass on everything accurately. And they may be uncomfortable delivering emotionally difficult information.

NCI adds three practical points. Telephone interpreters are about as accurate as in-person ones. In-person interpreters are still preferable for bad news or for chemotherapy consent. And the clinician should speak directly to the patient, not about her in the third person.

Billi's whole predicament is a job that was never hers to hold.

Almost nothing medical is shown, so almost nothing is misrepresented. It is still worth knowing what would have been there.

NCI lists the usual presenting features of non-small cell lung cancer. A worsening cough. Chest pain. Coughing up blood. Weight loss. Breathlessness. Hoarseness.

It adds a second set, caused by pressure on nearby structures. Trouble swallowing when the esophagus is squeezed. Hoarseness when the nerve to the voice box is involved. Swelling of the face and neck veins when the large vein returning blood from the head is compressed.

One test question would matter a great deal for a woman of the grandmother's generation. NCI reports that among lung adenocarcinoma specimens, EGFR exon 19 deletions and L858R turned up in 52 percent of tumors from never-smokers. In tumors from current smokers the figure was 6 percent. A never-smoker with advanced lung cancer has a real chance of a targetable change, and of a daily pill rather than chemotherapy.

NCI reports a 5-year relative survival rate of 29.5 percent for lung cancer overall among people diagnosed from 2016 to 2022. Split by how far it had spread, the figures were 65.5 percent for disease still local, 38.2 percent for regional spread, and 10.5 percent for distant disease.

Stage IV is that last figure. It explains why the family's arithmetic is not simply superstition. It also explains why the conversation they are avoiding is one about goals rather than facts.

Lung cancer is unusual among the cancers in this film library, because effective screening exists.

The USPSTF recommends annual low-dose CT for adults aged 50 to 80 with a 20 pack-year smoking history who either smoke now or quit within the past 15 years. It is a Grade B recommendation. One pack-year means an average of 20 cigarettes a day for a year.

Screening stops in two situations. Once someone has gone 15 years without smoking. Or once they develop a health problem that substantially limits life expectancy, or the ability or willingness to have curative lung surgery.

The 15-year rule confuses people, and NCI explains why it exists. Smoking raises lung cancer risk about tenfold on average, compared with a lifetime nonsmoker. NCI defines that as someone who has smoked fewer than 100 cigarettes. Risk climbs with the number smoked, the years spent smoking, and how young a person started. And quitting does not reset it. Former smokers stay at raised risk for years afterward, which is exactly why the screening window stays open that long.

Two details get missed. The 2021 revision widened the age range from 55 down to 50, and cut the threshold from 30 pack-years to 20. And the criteria set who is eligible, not who is safe. See lung cancer screening for what the scan can and cannot settle.

• https://www.cancer.gov/types/lung/hp/non-small-cell-lung-treatment-pdq
• https://www.cancer.gov/about-cancer/coping/adjusting-to-cancer/communication-hp-pdq
• https://medlineplus.gov/ency/patientinstructions/000445.htm
• https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening

This page discusses The Farewell for education. It is not medical advice, and nothing here is a judgement of anyone's real medical care. Spotted an error? Please email [email protected].