How does a doctor tackle the delicate issue of end-of-life care planning with a patient?
With an aging population and people living longer with chronic illness, it is increasingly important for patients and family members to decide how they and their loved ones would like to spend their final days. And for physicians in both hospital and primary care settings, it is crucial that they know how to address this issue with sensitivity.
A new "conversation guide" in CMAJ (Canadian Medical Association Journal) aims to guide physicians through these sensitive discussions with patients in hospital and their family members.
Although primary care physicians have an essential role to play in advance care planning, this review focuses on physicians and patients in hospital.
"A stay in hospital presents an important opportunity for engaging in discussions about goals of care, because it signals a change in the trajectory of the patient's illness, giving increased relevance to these conversations, and because potential substitute decision-makers (e.g., the most involved family members) are often present," writes Dr. John You, Department of Medicine and the Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, with coauthors.
"By providing structured guidance, specific advice and practical tools, our aim is to increase clinicians' confidence in engaging in meaningful end-of-life communication with patients in hospital and their family members," they write.
The authors provide a framework that will help inform decisions based on:
- identifying patients at high risk of dying
- communicating prognosis
- clarifying patient values around the care plan
- involving substitute-decision makers in care planning
- documenting a patient's wishes.
"Clinicians should exercise judgment and flexibility in engaging patients and family members in these discussions, recognizing that determining goals of care is a process. For patients who have existing advance directives, this process may be straightforward; for others who may be less prepared, the discussion may best unfold in a phased approach, with initial introduction and probing of this issue early during the stay in hospital and more detailed follow up later on," write the authors.
They suggest that efforts should be made to increase public awareness outside hospitals about the importance of advance end-of-life care planning and the limitations of life-sustaining technologies.