How Doctors Can Have End-of-Life Conversations with Patients
by Lisa DiFalco
As aging adults require additional assistance and need to make plans for the inevitable, it can be difficult for adult children and physicians to initiate sensitive conversations on nursing homes, final medical treatment options, potential incapacitation and more. Most adults are fearful of death and any complications for the living, but they also do not want to be a burden on those they leave behind.
There is more pressure on the healthcare community to support these difficult conversations, such as in cases when an individual becomes incapacitated. Californians get a new benefit with Medi-Cal and Medicare with “advance care planning” with physicians. The growing problem doctors face is that not everyone is gifted with a sensitive bedside manner, and many lack training on handling such difficult topics. Helen McNeal, executive director of the California State University Institute for Palliative Care, addresses the need of aging patients in Kaiser Health News:
“If you’re incapacitated, if you need someone to speak for you, who do you want to speak for you? And what would be your medical wishes?”
These conversations are important and help clarify patient wishes and reveal any associated costs and details to be considered with this newly-covered benefit for millions of Californians. However, aging adults in all states need to have conversations with family and potentially physicians as they transition to the next or final stage of their lives. Clear communication assists adults with having the final experiences that would support their changing needs. This challenge is not going away, but new resources are available to help with end-of-life conversations with aging adults. Learn how healthcare professionals can improve their ability to talk with aging populations about end-of-life needs today.
Conversations with Healthcare Providers
October is an important month in California, as Medi-Cal goes into effect and will cover advance care planning discussions. These conversations can be between healthcare providers and patients or their family members. Medicare began covering advance care planning discussions at the start of January. The coverage does differ between options but patients can choose to complete an advance care directive with either option. However, there is a problem that physicians are having, and will be having, with aging patients—many are uncomfortable having such conversations. A poll of over 700 doctors found:
“nearly half of [doctors] feel unsure some or much of the time about what to say when discussing end-of-life care with patients.”
In addition, findings show that less than 29 percent of those surveyed had had formal training focused on talking about end-of-life care with patients and families.
It is necessary to take a moment to digest this information. Physicians and healthcare providers tasked with this conversation are often not prepared to initiate these conversations. Physicians who could be talking about this topic with aging patients and supporting such dialogues with patients and families are not ready. What can be done to create more confidence in physicians and give them additional insight into advance care planning and related conversations?
Support for Difficult Conversations with Aging Adults
Doctors and qualified healthcare providers now have assistance with tackling this sensitive issue. There are a number of resources to help. Consider:
- Reviewing End-of-Life Discussions: The Art of Delivering Bad News to plan to address end-of-life issues, decide when to initiate conversations, find out whom to include in the conversation and be aware of other general guidelines;
- Watching The Conversation video from the Rock Center that shows an actual dialogue between physician, patient and family. The physician calmly and compassionately guides the patient through a series of advance care planning questions;
- Learning more about advance directives by state from the National Hospice and Palliative Care Organization;
- Honing communication skills for patient-centered advance care planning from AAFP that provides key recommendations for the late stage of a disease, identifies phrases to avoid or clarify, addresses cultural diversity and individual preference and more; and
- Viewing the Frontline video, Being Mortal, from the perspective of Atul Gawande, Boston surgeon, as he discusses doctor-patient relationships as patients get closer to the end of their lives, his own experience with his father and the often uncomfortable situations being pressed upon physicians.
Even when hospitals, clinics, health centers, and geriatric communities do not currently offer training, there are videos, webinars, courses and resources available online that can assist in educating health professionals. Doctors and staff can learn to better engage aging adults and discuss the alternatives necessary as patients get older, need additional assistance, or have to come to terms with their final wishes when it comes to their health needs. Those that are terminally ill and in their final stage of life need compassionate care as they surrender to the inevitably of death and live the last period of their life with a sense of dignity. Atul Gawande said:
“The simple view is that medicine exists to fight death and disease, and that is, of course, its most basic task. Death is the enemy. But the enemy has superior forces. Eventually, it wins. And, in a war that you cannot win, you don’t want a general who fights to the point of total annihilation. You don’t want Custer. You want Robert E. Lee, someone who knew how to fight for territory when he could and how to surrender when he couldn’t, someone who understood that the damage is greatest if all you do is fight to the bitter end.”
Families, mental health professionals, case managers, and doctors need to take the next steps in preparing for talking about death and gather guidance and support for aging adults that deserve to live and die on their own terms. These important conversations must happen and health providers are in the perfect place to facilitate potentially emotionally charged conversations and objectively offer the options best suited to an individual’s unique situation. Resources and support continue to emerge to provide qualified professionals with guidance in carrying out this important responsibility with patients.