Published in the February 2007 issue of Today’s Hospitalist.
If there’s one area where you as a hospitalist can improve your skills in treating patients at the end of life, it’s in how you talk to these individuals and their families.
That was one of the messages delivered by Steven Pantilat, MD, during a presentation on end-of-life care at last fall’s University of California, San Francisco (UCSF) annual meeting on managing hospitalized patients.
Dr. Pantilat, a hospitalist and one of the nation’s top authorities on end-of-life care, said that the opportunity for hospitalists to get involved in end-of-life care communication is obvious. Optimal end-of-life care requires a team approach, and because many patients are hospitalized intermittently during their final days, hospitalists have a chance to play a central role on that team.
But Dr. Pantilat, associate professor of clinical medicine at UCSF and founding director of the palliative care program there, said that for many physicians, communication skills remain a challenge.
That difficulty clashes with the expectations of dying patients and their families, who, Dr. Pantilat said, look to the health care system to provide not only relief of physical symptoms-namely pain, shortness of breath and fatigue-but communication and support.
Studies have shown that patients and their families want information about illness and death, including what they can expect to happen to them. They also want psychosocial support, and they don’t want to be abandoned.
To help hospitalists talk to both patients at the end of their lives and their families, Dr. Pantilat outlined communication strategies to meet these patients’ needs.
Talking to patients
Once you’ve unearthed information about a dying patient’s hopes, values and fears, you can translate their complaints about pain, nausea and feeling short of breath into appropriate medical interventions, whether it’s an ICU admission or palliative measures.
"Patients don’t come in asking for measures by name," Dr. Pantilat said. By discussing their goals and complaints, he added, physicians get a better idea of how to choose interventions that will meet patients’ needs, particularly if they want fewer interventions.
"You want people to have a realistic sense of what is going on so that they can have hope, based somewhat in reality," Dr. Pantilat said. Because all of us would live our life differently to some degree knowing we had only one year left, he said, "I think we owe this information to our patients."
Besides, he added, it’s naive to think patients haven’t considered the possibility and timing of their death, particularly if they have a serious chronic illness. If you would not be surprised to hear that a patient dies in the next year, Dr. Pantilat said, that person probably deserves the benefit of a conversation about prognosis.
"If we raise the issue," he pointed out, "it will be a relief to them to know that they can talk about their concerns."
As a result, he tends to ask the following kind of question: "I have information about your condition. Some patients want to know the details, and others prefer to have me talk to someone else. How do you feel about it?"
A good example is resuscitation. One big take-home message of all the wildly popular television medical programs is that there is a good chance of surviving a code blue. As a result, Dr. Pantilat said, nearly one-half of those with chronic illnesses say they want doctors to try to restart their heart, adding that they believe they have a good chance of being revived.
Studies have shown, however, that when these patients are informed of their real chances of surviving a code, one-half change their minds about wanting resuscitation.
"We don’t talk about prognosis because we worry that we don’t have a crystal ball," he said. "The solution is not to talk in absolutes."
When he talks about prognosis, Dr. Pantilat explained, "I no longer say to someone, ‘Six months.’ I talk about ‘hours to days,’ ‘days to weeks’ or ‘weeks to months.’ This communicates the inherent uncertainty of prognostication while still giving people useful information."
Talking to families
"Be curious," he said. "Ask family members what you need to know about their culture or religion to help you take care of their family member." As for family members who try to talk him out of breaking difficult news to a patient, Dr. Pantilat said, "I try to convince the family to let me tell."
Studies, he added, have shown that patients "usually know more than we or the family think." In fact, giving bad news to patients often spurs them to have the frank and useful discussions with their family that they’ve been avoiding because they know the family doesn’t want to raise the subject.
"It’s important to change the idea of ‘I abandoned my mom at the moment she died’ to ‘She waited for me to leave before she died,’ " Dr. Pantilat said, saying that this information is actually very powerful. "Otherwise, people can feel guilty for a very long time" that they stepped away from a loved one’s bedside to visit the hospital cafeteria.
While much attention has been paid to improving end-of-life care, only 28% of Americans die at home. That’s one-half the number who, on surveys, report a preference for dying at home.
Although the number of Americans enrolling in hospice care has increased over the past few years, those figures are still very low relative to the benefit hospice can provide. Dr. Pantilat said that’s due partially to the fact that many physicians
do not refer their patients to hospice or do not refer them early enough.
Deborah Gesensway is a freelance writer who reports on U.S. health care from Toronto, Canada.
The prognosis: Pinpoint accuracy isn’t as important as providing a ballpark estimate.
Phrases you should avoid during end-of-life discussion
Along with discussing ways physicians should communicate about the end of life, Steven Pantilat, MD, founding director of the palliative care program at University of California, San Francisco (UCSF), underlined these phrases that you should do without:
Instead, Dr. Pantilat recommended the following: "I wish there was something we could do to make your [name of condition] better." That "I wish" statement, he said, "puts me on the same side as the patient."
The problem, he explained, is that this question means something different to patients and their families than it does to physicians. "The family thinks it means ‘everything possible that is going to help,’ " he said. They do not mean, " ‘do everything possible’ that is going to lead them down some road that they never intended to be on."
Instead, Dr. Pantilat recommended asking the following question: "How were you hoping we could help your mother?" Asking the right question, he explained, can completely change the course of care.
"Should we withdraw care?" This is another phrase that isn’t any good, Dr. Pantilat said, because "we never withdraw care. We always care for the patient" even after life-sustaining interventions are withdrawn.
While it may feel awkward, Dr. Pantilat said he always forces himself-and his residents-to say "withdraw life-sustaining intervention" instead of "withdraw care." It is a constant reminder to themselves and to patients, he said, that "we never stop caring."