You’ve asked your patient all the standard questions about diet, smoking, and exercise during the annual physical exam. But there may be one more question you should ask: Have you thought about your end-of-life wishes?
The conversation that follows may be awkward, but by encouraging patients to share their vision for a “good” death, physicians can help patients decide which end-of-life interventions they would or wouldn’t want to receive, DOs say. In this edited interview, three DOs share their strategies for raising the topic and offering guidance as patients consider their final wishes.
Starting the conversation
Discussing end-of-life preferences is difficult for many patients, so it’s important to be sensitive, physicians agree. Joe McCue, DO, a family medicine resident in Columbus, Georgia, raises the question when adult patients visit him for annual physical exams.
“I frame it as, ‘Confronting these uncomfortable things now could prevent your loved ones from anguishing over what you might have wanted,’” he says. “Accidents do happen, so it’s a good idea to think about it so we can make sure the end of your life is as good as the rest of your life.”
Dr. McCue and Kitt Klaiss, DO, say they encounter varied reactions when broaching end-of-life wishes with patients. “Some people are willing to talk about it and plan ahead, but some don’t even want to think about it because reflecting on their own death freaks them out,” says Dr. Klaiss, a primary care physician in Tuscaloosa, Alabama. “If they seem really closed, I drop it and move on.”
For patients with serious chronic illnesses or those who are near the end of life, however, the conversation may be easier, says hospice and palliative care specialist John F. Bertagnolli Jr., DO. “My patients usually know what they want and are relieved to be asked, because they don’t know how to bring it up,” says Dr. Bertagnolli, who practices in Stratford, New Jersey. “The family often gets upset: ‘Mom’s not dying yet!’ But they almost always thank us later for learning exactly what their loved one wanted and making the process a little bit easier.”
Charting a course
When his hospice and palliative care patients consider the end of life, Dr. Bertagnolli asks them what their goals are. “Patients might want to die at home, to be sure their bills are paid, to be comfortable and free of pain, or to avoid feeling they are a burden to their family,” he notes. Based on their responses, Dr. Bertagnolli discusses how interventions like receiving CPR, being intubated or receiving artificial nutrition and hydration would align with their wishes.
When patients detail the end-of-life interventions they would or wouldn’t want to receive, Dr. McCue is careful to give a realistic description of what various procedures entail. He points out that intubation has potential complications, particularly if done long-term, and that effective CPR is likely to result in broken ribs. “If you come back from chest compressions after CPR, you will be in a large amount of pain,” he says. “That’s absolutely appropriate if that’s your choice, but people need to know that.”
DOs’ holistic approach lends itself especially well to end-of-life care, Dr. Bertagnolli says. He described caring for a hospice patient who was taking medication to alleviate discomfort, but was still in significant pain and unable to sleep.
“Pain management isn’t just about physical pain; it’s also about addressing psychological pain and spiritual pain,” Dr. Bertagnolli says. He learned the man had a 17-year-old son who would be graduating from high school soon—an event the patient feared he would not live long enough to attend.
In response, Dr. Bertagnolli and his colleagues organized an early graduation ceremony on a Friday evening at the patient’s home. The man’s son, joined by a few friends and the school principal, wore his cap and gown. “The dad had a glass of wine in his wheelchair and toasted his son,” Dr. Bertagnolli says. “The next morning, he passed away.”
For Dr. McCue, such stories illustrate the importance of discussing the sensitive questions that surround the end of life. “Death is a normal part of life, just as birth is a normal part of life,” he says. “As physicians, our job is not only to make sure a patient has the healthiest life possible, but to make sure they have a dignified death that is in keeping with their wishes.”