When it comes to providing end-of-life care to a patient, treatment decisions are not always black and white. In fact, a lot of gray area exists.
Does an advance directive exist? Do family members know what type of care their loved one wants? Are there legal ramifications if a doctor goes against a patient’s wishes? All of these are questions medical professionals face in determining the care a patient receives.
An educational module from the AMA seeks to help medical residents and fellows understand the answers to these questions and demonstrate the impact each answer can have on a treatment plan. “End-of-Life Care” is one of the AMA GME Competency Education Program offerings, which include nearly 30 courses that residents can access online through their institution’s subscription, on their own schedule.
Among the program’s experts are several who contributed to the AMA’s Health Systems Science textbook, which draws insights from faculty at medical schools that are part of the Association’s Accelerating Change in Medical Education consortium.
Modules cover five of the six topics—patient care, practice-based learning and improvement, interpersonal and communication skills, professionalism, and system-based practice—within the Accreditation Council for Graduate Medical Education’s core competency requirements. The sixth requirement, medical knowledge, is one that is typically addressed during clinical education.
A foundation to build on
End-of-life care is a difficult and emotional topic, particularly in the moment, and tensions can quickly escalate among family members or between families and physicians when it comes to determining the best course of treatment.
That is where an advance directive can be particularly useful. The goal of an advance directive, according to the module, is to allow patients to spell out “decisions about end-of-life care ahead of time. They give you a way to tell your wishes to family, friends, and health care professionals and to avoid confusion later on.”
The 19-minute module teaches residents more about advance directives and living wills, and it provides a foundation for residents to build on throughout their career that will help them:
- Identify the goals of advance care planning.
- Define the different types of advance directives.
- Explain their rights and responsibilities as a physician in terms of advance care planning.
- Describe common patient and family concerns surrounding end-of-life issues.
- Identify when to broach the subject of end-of-life planning.
The module also helps residents walk through examples of effective communication with patients and their families concerning end-of-life acceptance and strategies.
Most patients lack directives
Only 20% of patients have an advance directive documenting their wishes, according to the module. Of those without a directive on file, 60% were unfamiliar with what it was, 14% thought they were too young and healthy to need one, and 11% didn’t understand the document.
Based on those statistics, patients need to be better educated about advance directives. Physicians can help with this by explaining what an advance directive is as part of a routine appointment or conversation—while acknowledging that the topic is a hard one to consider. Educating patients can also include dispelling common patient myths, including the false assumption that patients who have advance directives will not receive the same standards of care if they become ill.
A physician’s responsibility
Beyond educating patients, physicians need to always remember that it is up to them to:
- Reassure patients that their wishes are to be followed.
- Make patients as comfortable as possible.
- Manage pain and let the disease take its course.
- Provide comfort, care and symptom management.
- Make recommendations or advise the patient as needed.
No type of advance preparation will change the reality of an end-of-life situation, but empathy and an advance directive will hopefully make an uncomfortable situation a little easier to get through.