We had the opportunity to speak with Dr. Jessica McCannon, M.D. a physician with Massachusetts General Hospital specializing in Pulmonary Critical Care about the end-of-life conversation that doctors have with their patients.
Dr. McCannon is passionate about the topic, she confronts it nearly daily in her practice. She collaborated with The Conversation Project, a non-profit that is specifically geared to having “that conversation” with your doctor. Dr. McCannon helped to created the Starter Kit, a guide for patients and physicians facing end-of-life decisions.
How do you begin the end-of-life conversation with a patient?
It obviously depends on the context, and I think this is part of what makes it complicated – you have to constantly adjust for the situation. In the ICU, it might have to happen quickly; then you have to establish immediate rapport with the decision makers, both family members and patients.
The other extreme is the outpatient setting. In that setting, it’s about the right time to bring it up. I rarely, if ever, bring it up on a first visit with a patient. I try to bookmark it for a later visit. You can prepare the patient by giving them a copy of the Conversation Project Kit and come back and talk about it later.
How do you work with a resistant patient?
Some people just don’t want to talk about it, so a lot of times the medical decisions are left in the hands of the physicians, and the family which is why the Conversation Project exists: to help people get there. I think you have to acknowledge that it’s hard for them. Is it fear? What kind of fear? Is it fear of death or that they’ll be abandoned by the medical system or fear of leaving their families?
I think some of this you can work at over time. The patient needs to feel in control. It’s not just a one time decision either, what feels right on Day X may not feel right 30, 60 or 90 days from that day.
I also let them know I talk to all of my patients about this, I’m not singling them out. I ask because I want to get to know them better.
Can they feel overwhelmed?
There is the extreme of doing everything and then there is the extreme of palliative care and there is so much in the middle. There are all sorts of decisions that people have to wrap their heads around both from thinking about where someone would want to live and certain illnesses may be managed more aggressively than others. There are also financial and spiritual decisions.
We give them all this information and then say, ‘here, you make the decision.’ Sometimes in talking to colleagues the pendulum seems to be shifting the other way where the doctor will guide them through a smaller range of options.
Any closing points?
Dr. Katharine Treadway M.D. always talked about asking the unscripted question. If you can do that and angle it at understanding the person better than I think even if you don’t have the nitty-gritty of a medical decision you can make better decisions. If you know that a patient really wanted to travel to Ireland, it’ll give you the sense for what they’re willing to push for or give up. Get back to where you were as a medical student. Get to know your patients.
Please check out the information available at The Conversation Project and let us know your thoughts either below or inside Sermo if you’re an M.D. or a D.O. We’d love to hear from you.