Research increasingly supports the value of palliative care – the earlier, the better.
What physicians say and how they say it can shape the trajectory of care, including decisions about treatment options and end of life. Open, continuing discussion of prognosis, goals and patient preferences has many benefits, including improved quality of life and symptom burden, and reduced healthcare utilization.
Communication about the end of life is challenging and requires deliberate practice. Many barriers exist, including uncertainty of the best timing; concern about family dynamics or patient wishes; lack of time; inadequate training or support; and prognostic uncertainty.
Unfortunately, these conversations often occur during acute hospital care, with providers other than oncologists and late in the course of illness. Physicians should consider beginning discussions with any patient who might pass away within one year.
An accurate perception of prognosis ensures that choices reflect the patient’s true values, including less aggressive treatment at end of life. Having an accurate prognosis does not negatively impact outcomes, survival – or even hope.
In a successful conversation, you will: provide evidence, including a balanced discussion of uncertainties; gain a better understanding of patients’ experience and expectations; present recommendations informed by clinical judgment and patient preferences; and check for understanding and agreement.
In general, approach gently and ask for permission to have the discussion. Start with a concise sentence, such as “I am worried that this is as good as you will feel” or “I am worried that time may be very short.”
Tailor your conversation to each individual patient. Ask questions and make empathic statements. Allow for silence and support emotion.
It helps to develop a roadmap – such as the “REMAP” pneumonic -- to guide your overall approach.
R: Reframe the situation. (“How do you feel things are going?”)
E: Expect emotion. (“I understand how difficult this can be.”)
M: Map out values. (“What is most important going forward?”)
A: Align with the patient and family. (“As I listen … a few things stand out …”)
P: Plan treatments to uphold values. (“Based on what you said, these are the things we can do …”)
Having difficult conversations is worth the time and effort. In the end, you will build a stronger partnership with your patients and their families.
-- Source: “Palliative Oncology Principles: Evidence for your practice and timing of specialty referral”
Kristina Newport M.D., Director, Outpatient Palliative Care, Hospice & Community Care; Shanthi Sivendran, M.D., MSCR, LG Health Physicians Hematology & Medical Oncology; and Anjana Ranganathan, M.D., Hematology/Oncology and Palliative Care, Penn Medicine
Kristina Newport, M.D.
Shanthi Sivendran, M.D.
Anjana Ranganathan, M.D.