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Terminally ill patients and their families often want to know to everything about the prognosis
The problem with delivering the worst news to a patient isn’t just that the task is inherently hard. It’s also that such a task is generally not part of physician education, says Diane E. Meier, MD, professor of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai.
“It is not an easy conversation, and it requires training,” says Dr. Meier, who is also director of the Center to Advance Palliative Care. “It’s a procedure, and it can be taught like any other procedure.”
Providers must take into account any advance directives and identify the key decision maker within the patient’s family, says Michael Malone, MD, chair of the American Geriatrics Society’s Public Policy Committee.
A series of steps can help physicians through the process.
The physician should make recommendations, not just ask, for example, whether a spouse wants her husband put on a ventilator.
Providers must listen-actively. Ask what the patient was like before the current illness or crisis. Ask if the family or spouse wants further information about treatment or prognosis and how much detail they’re comfortable with. Most will want to know everything. “But don’t tell people what they don’t want to know,” Dr. Meier says.
Regarding the crux of the matter, simply say, “I’m sorry to say that Mr. B. isn’t responding to x” -or whatever the case might be-”and he’s dying.”
Dr. Meier says families at this point in the interaction are often relieved to get straight information, but they still need to process it.
When the family or spouse has had at least a few minutes to start to absorb the prognosis or treatment outcome, continue by saying something like “In my medical judgment, I recommend that …” For example, a physician might suggest the patient be kept on a ventilator long enough for family members to be notified and to gather.
Get a chaplain and/or social worker involved, as needed. If the physician makes sure that the family understands what’s happening, says Dr. Malone, and that pastoral care is provided, if appropriate, it will go a long way toward ensuring that the approach remains “a thoughtful, patient-centered process.”
Watch the Center to Advance Palliative Care video “Palliative Care and the Human Connection: Ten Steps for What to Say and Do" here.