In many cases, physicians do not routinely initiate end-of-life discussions until late in the disease course. Effective communication skills are key at this critical time when patients and their loved ones must often make difficult decisions, but many physicians often do not know where to start.
Palliative care experts Rebecca Sudore, MD, from the University of California, San Francisco, and Rachelle Bernacki, MD, from the Dana-Farber Cancer Institute in Boston shared several tips for having these challenging conversations.
Start the conversation early. The ideal time to discuss end-of-life care is when a patient is relatively healthy. In a recent survey conducted by the Kaiser Family Foundation, a majority of patients agreed they would be comfortable discussing advance care planning with a physician. Sudore suggests simply asking, “If needed, due to illness or an emergency, is there anyone you trust to help make medical decisions for you? Can we talk about this today?”
Providing patients with easy-to-understand educational materials and asking them to review the resources by the next visit is another way to start the discussion.
Identify patient values and goals. End-of-life planning revolves around patient values and goals. Sudore recommends asking patients about friends or family members who have experienced serious illness and consider what went well, what did not go well, and their preferences in similar situations. “Personal stories can be very powerful ways to help people identify their own values and goals,” she says. Ask patients to identify their fears and worries, what gives them strength, and what makes life worth living.
Offer support and honesty. When discussing a serious illness, it is important to identify the patient’s current level of knowledge. Bernacki suggests asking: “What is your understanding now of where you are with your illness? How much information would you like from me?”
When bringing up a difficult prognosis, Bernacki says, it is important to soften language but still be truthful. “We suggest saying something like: ‘I wish we were not in this situation, but I am worried that time may be as short as days to weeks.’”
“Typically, physicians revert to talking about the disease and medical details,” Bernacki adds. “We spend a lot of time teaching physicians how to respond to emotion.”
For patients who are terminally ill, “It’s really important to say: ‘I will continue to be your doctor and care for you, no matter what,’” Bernacki says. “The worst feeling a patient can have is feeling abandoned.”
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