Roadmap guides end-of-life care discussions, decision-making

Canadian researchers have compiled a "conversation guide" to help steer clinicians through important end-of-life discussions.

According to article published online Monday in the Canadian Medical Journal, the guide focuses on identifying patients with whom conversations should be held, the most effective ways to provide information, and how discussion and deliberation can lead to important decisions.

"By providing structured guidance, specific advice and practical tools, our aim is to increase clinicians' confidence in engaging in meaningful end-of-life communication with patients in hospital and their family members," the authors wrote.

Specifics include:

  • Ask the question "Would I be surprised if this patient died in the next year?," supplemented by objective criteria such as age, chronic conditions and recent hospitalizations, to identify patients with whom end-of-life issues should be discussed.
  • Aim to understand what outcomes the patients considers acceptable, and how changes in their health might change those values.
  • Explain the risks and benefits of life-sustaining therapies.
  • Involve substitute decision-makers such as family in the discussion, ensuring they understand the patients' wishes so they can make difficult calls regarding appropriate therapies when the time comes.
  • Have patients establish any leeway they want granted to the substitute decision-makers in advance.
  • Explain the physician's role is to carry out the patients' wishes if it conflicts with that of substitute decision-makers.
  • Document the discussions and the resulting decisions.

The conversation guide includes suggestions, such as how to phrase questions to elicit answers, and a step-by-step guide to explain patients' prognosis and respond appropriately to patients' reactions. It also includes suggested questions to understand goals of care and different ways to approach decision-making.

The importance of those discussions was highlighted by a separate study published earlier this year in JAMA Internal Medicine, which found 75 percent of elderly patients in Canada at high risk of dying within six months had discussed their goals for care with a family member, but most had not shared those thoughts with their primary care providers or hospital clinicians. In addition, wishes noted in their medical records usually differed from what the patients and their families told interviewers.

"That to me is a huge and alarming problem, that an 80-year-old patient says, 'When it comes to the final stages of life, just focus on keeping me comfortable,' and on their medical record, they're up for full resuscitative practices," said Daren Heyland, M.D., lead author of that study.

To learn more:
- here's the CMA article (subscription required)
- see the abstract from JAMA Internal Medicine

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