Conversations about dying and end-of-life care are among the most challenging communication scenarios for physicians. Diagnosis, prognosis, treatment goals and end-of-life wishes all may be difficult topics to discuss, but research has identified protocols that can ensure end-of-life conversations are meaningful, comprehensive and effective, particularly when input from multiple disciplines is needed.
The AMA Code of Medical Ethics provides additional guidance on end-of-life care, such as chapter 5, “Opinions on Caring for Patients at the End of Life,” which covers topics such as advance care planning, advance directives and orders not to attempt resuscitation.
Following are highlights from an article in AMA Journal of Medical Ethics® (@JournalofEthics) by Mark Pfeifer, MD, professor of medicine, and Barbara A. Head, PhD, associate professor at the University of Louisville School of Medicine. The article draws from multiple communication models to provide guidance for physicians and their colleagues from other disciplines in this delicate situation.
Make the conversation a team effort. Dying involves psychological, social, spiritual and financial concerns, so the ideal team would include professionals from medicine, social work, nursing and chaplaincy to address the varying needs of the patient and the family.
The social worker’s responsibilities might already include initiating discussions and providing counseling. Likewise, the team nurse can provide ongoing medical monitoring and instruct patients about treatments and medications, and the chaplain may address the patient’s spiritual needs. By dividing responsibilities among team members, pressure on the physician to “do it all” is alleviated.
Ask the patient whom to include. Based on this, you can plan for any issues that might affect the discussion. Family members may have conflicting attitudes towards the patient’s wishes, and it is easy for conversations to be derailed by their opinions, needs and emotions. Physicians have a responsibility to acknowledge family issues but to continually bring the focus back to the patient and the current situation.
Have a goal for each meeting. This might be to deliver serious news, clarify the prognosis, establish goals of care or communicate the patient’s wishes. Clinicians should also ascertain how much information patients want—for example, whether they prefer all the details or just bottom-line recommendations.
Set aside adequate time. End-of-life discussions are challenging to integrate into routine hospital rounds or office visits, and time constraints are often cited as a barrier to end-of-life communication. Schedule meetings for when there is time to patiently listen, reflect and discuss next steps.
Find the right location. Ideally, these conversations would take place in a quiet room, free from interruptions, although they are often held at the bedside because of the patient’s condition or a lack of space. Either way, sit down, as standing above a critically ill person can add to his or her feelings of vulnerability. Sitting projects patience and a caring attitude.
Have an outline, but be flexible. The patient is the most important member of the team, and his or her preferences and informational needs should guide the meeting. Steer clear of being what surgeon and author Atul Gawande, MD, MPH, calls an “explain-aholic.” You can avoid dominating the conversation by adopting a listen-first approach and keeping in mind the “20 percent rule”—that patients might only remember about 20 percent of what is said in the first discussion because their emotional response may impair their memory.
More help here
It might seem that some physicians are naturals at end-of-life conversations, but empathic communication can be learned like any other clinical skill. AMA Journal of Medical Ethics has produced several “Ethics Talk” podcasts on this topic, including “Healthy Dying and How It Can Happen” and “Facilitating End-of-Life Care Discussions through the Conversation Project.”
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AMA medical student members: View the April 11 Facebook Live broadcast in the AMA medical students Facebook Group, featuring guest expert Dr. Nicole Piemonte on the importance of end-of-life conversations and how to transfer the necessary skills from classroom to clinic.