Evidence shows that patients who have had end-of-life discussions with their physicians are more likely to die at home or in a comfortable setting, instead of in a hospital intensive care unit. Not only is this seen as a kinder, gentler way to die, it’s a lot less expensive than being attached to tubes and machines.
This is, no doubt, the reason Medicare, beginning in 2016, will start reimbursing doctors for having end-of-life talks with their patients. Private insurers are likely to follow Medicare’s precedent.
Trained to save lives at all costs, most physicians are reluctant to initiate end-of-life discussions with their patients. “Death has long been regarded as tantamount to medical failure, which implies that physicians have nothing to offer a dying patient and family” (Journal of General Internal Medicine, March 2000). Consequently, doctors prefer that patients bring up the topic. But the majority of patients say it’s the doctor’s duty.
Dr. Diane Meier of Mount Sinai Hospital agrees: “Part of our job as physicians is to get people to pause and reflect upon what’s important to them” at the end of life (The Wall Street Journal, September 28, 2015). But it’s a mistake to wait until the patient is diagnosed with a serious, life-threatening illness, because it can be difficult for patients and their families to think clearly once a health crisis occurs. That’s why Dr. Meier advocates that advance-care planning become “an integral part of routine adult primary care” in the same way that we talk about smoking, high blood pressure, and cholesterol control.
1. Make end-of-life discussions part of your practice.
2. Take the lead, ideally when patients are well.
3. Set aside enough uninterrupted time for the conversation.
4. Involve other adult family members whenever possible.
5. Don’t inject your personal opinions and biases.
6. Avoid jargon, like DNR for “do not resuscitate.”
7. Be specific. Ask what patients and their families want done and not done under various circumstances.
8. Encourage the patient to speak openly about their fears.
9. Give the patient time to become comfortable with their decision,
reassuring them that they can always change their mind.
Ken Teufel, M.D., M.A.