Death is in the medical news again. The Institute of Medicine (IOM) recently published a detailed position paper entitled Dying in America: Improving quality and honoring individual preferences near the end of life.1 In the report, the authors note a need for “developing clinicians’ ability to talk effectively to patients about dying and teaching them to take the time to truly listen to patients’ expression of their concerns, values, and goals.” They make recommendations to clinicians, educators, public policy makers, and payers on ways to remedy the situation.
Advanced care planning and end of life conversations are time consuming, and poorly reimbursed. They are difficult for physicians and patients for a variety of other reasons, including fear, denial of death, and the medical imperative to do more.
I’ve recently been teaching courses on “Crucial Conversations” developed by an organization called VitalSmarts.2 A crucial conversation is a conversation characterized by high stakes, opposing viewpoints, and high emotion. Conversations at the end of life are often crucial. The goal of these conversations is to elaborate the goals of care with the patient. The physician and patient contribute to a pool of shared meaning: the patient (or surrogate decision maker) shares her values, preferences, and goals regarding medical care; the physician shares his medical experience, evidence from the literature, and knowledge. Through back and forth dialogue, they come to a decision together. It is more than information sharing. The physician makes it safe and easy for the patient to share her feelings, values, and preferences so that decisions can be made that are consistent with her values. This kind of safe, rich conversation is only possible if the physician listens well, shows empathy, and puts the patient’s interests above his own. It is a conversation grounded in honesty, respect, mutual purpose, and trust.
This is easier said than done. With practice (and time!), physicians can learn to have crucial conversations that further the interests and goals of their patients, particularly at the end of their lives.
–Dean Gianakos, MD, FACP
Dean Gianakos, MD, FACP, practices and teaches general internal medicine in the Lynchburg Family Medicine Residency and Geriatrics Fellowship, Lynchburg, VA. He frequently writes and lectures on the patient-physician relationship, end-of-life care, and the medical humanities.
References
- Institute of Medicine. Dying in America: Improving quality and honoring individual preferences at the end of life. Washington, DC: National Academies Press, 2104.
- Patterson, K. et al. Crucial Conversations. USA: McGraw-Hill, 2012.