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Podcast Recap | Intention to Treat: Why doctors need to talk about death

March 21, 2024

In this episode of The New England Journal of Medicine’s podcast Intention to Treat, Vicki Jackson, MD, Nneka Ufere, MD, and host Rachel Gotbaum explore the importance of clinicians discussing death with their patients over time. They provide insights on palliative care communication training and how it can support healing and create stronger bonds across clinician disciplines.

Podcast Length: 23 min., 23 sec.

5 Key Takeaways

1. Starting conversations about death with patients and their families early on can be healing.

It's crucial to have a conversation in the early stages of a critical or chronic illness when the patient and family still have a long road ahead. By beginning the conversation at the start of an illness, clinicians give patients the ability to have a say in their end-of-life care. The more time you give patients and their loved ones to think about what happens if they don't recover, the more time they have to prepare. Jackson also explains that clinicians should be prepared to have a number of these conversations over time. “It is difficult to come to terms with one’s mortality. And part of the skills we have to help clinicians build is how do we support patients in integrating this information over time as they’re making sense of their illness trajectory,” said Jackson

2. Limited training for discussions about death is distressing and harmful to clinicians and the health care industry.

When clinicians don't feel comfortable having tough conversations, they typically avoid the subject. Dr. Ufere describes the serious illness communication training she received during her residency with the palliative care division. This training was the only time she was exposed to end-of-life discussions before her gastroenterology and transplant hepatology fellowship. The minimal guidance left her without the skills to have these discussions with her patients.

Without palliative care communication skills, clinicians can feel overwhelmed. During Dr. Ufere's training, she noticed limitations. She was caring for patients hoping for liver transplants, but she lacked the knowledge to help them navigate the possibilities of disease progression, causing her much distress. Clinicians need comprehensive training to become more comfortable having end-of-life conversations.

3. Conversations about death are tough, but knowing what to expect can be helpful.

In end-of-life conversations, clinicians continually assess what patients understand about their illnesses. Clinicians can gauge where the patient's knowledge is and how they are coping with the changes throughout the disease.

Dr. Jackson mentions that communicating with the patient about their illness is vital, but it's also essential to understand the psychological adaptation required of the patient. Frequently, clinicians become frustrated when a patient doesn't seem to grasp the severity of their condition and prognosis. Clinicians should expect patients to have a range of emotions when learning of a severe illness. They should also keep in mind that coming to terms with one's mortality is not easy.

4. Some residents undergo palliative care communication training, which can provide valuable information for clinicians who need to improve their communication skills.

As chief of the palliative care team at Massachusetts General Hospital, Dr. Jackson discusses the importance of communication training. Clinicians should learn to ask open-ended questions such as, "What is your understanding of your illness?," "What are you worried about?," and "Thinking ahead, if you got sicker, what would be most important to you?" These questions should focus on the patient and allow them to talk about what they are experiencing. With open-ended questions, clinicians can have deeper conversations with patients and learn more about their values.

While this training focuses on communication, Dr. Jackson explains that it also covers patients' differing emotions following diagnosis. Clinicians learn how to recognize emotions and respond to patients' feelings.

5. Integrating palliative care communication skills into clinician routines boosts relationships across disciplines.

After training, clinicians can shift to a more holistic approach. Dr. Ufere discusses the change in her practice, stating that her conversations were initially focused on hope and not describing the what ifs. Covering many possibilities will help the patient understand more about the illness and what to expect.

Dr. Ufere's residency training can be replicated for more clinicians, allowing a patient's health care team to collaborate. Adding these communication skills into routine practice creates a cultural shift in health care. To ensure that all clinicians on a patient’s care team know what has been discussed, Dr. Jackson recommends placing notes about serious illness conversations in the patient's electronic health record (EHR). Clinicians can also note what procedures the patient understands and their wishes. This increased access closes the communication gap to ensure the patient's end-of-life plans are clear.

Any views, thoughts, and opinions expressed in this podcast recap are solely that of the host and guests and do not reflect the views, opinions, policies, or position of epocrates and athenahealth.

Source:

Gotbaum, R. (Host). (2024, February 15). Why Doctors Need to Talk about Death (Episode 26) [Audio podcast episode]. In Intention to Treat. The New England Journal of Medicine, 390, e15. https://www.nejm.org/doi/full/10.1056/NEJMp2314001