End-of-Life Care Discussions Should be Initiated Earlier

This can help patients reduce suffering, make more informed choices, and attain life closure

Discussions about end-of-life issues between patients, their families and health care clinicians are difficult for clinicians to initiate, but by doing so earlier and more systematically than is typical, clinicians can better serve patients and their families, according to an article in the November 15, 2000, issue of The Journal of the American Medical Association, a theme issue on end-of-life care.

Unfortunately, palliative care [making a patient more comfortable by treating a patient's symptoms, rather than curing the patient] is frequently offered late in the dying process, if at all, and as an alternative to usual medical care as opposed to something that can enhance or supplement it.  Hospice, a system for providing palliative care, is underused even for patients with advanced cancer.

Physicians are also reluctant or unable to tell patients that they are likely to be approaching the end of their lives. When physicians do talk about prognosis, they tend to be overly optimistic. This inability to relay unfavorable prognostic information results both from medicine's inherent prognostic uncertainty and from clinicians' fears that they will be perceived as 'giving up' if they talk about dying, thereby eliminating hope and depressing patients. However, studies have found that not only is this not necessarily the case, but failure to provide appropriate information about palliative care and prognosis can contribute to unnecessary pain and suffering."

Consensus has evolved among clinicians that meaningful end-of-life options are usually offered too late. Fewer physicians agree as to the clinical markers signaling the time to initiate discussions.

The following situations suggest urgent indications.
Patients facing imminent death
Patients who talk about wanting to die
Patients recently hospitalized for severe progressive illness
Patients suffering out of proportion to prognosis

Normalizing the discussion allows patients to learn about their right to high-quality pain and symptom management and educates clinicians about patient's values and goals. Asking 'What would be left undone if you were to die sooner than later?' gives a message that time may be short."

Indications for routine discussions might be:

When discussing prognosis
When discussing treatment options with a low probability of success
When discussing hopes and fears
When the physician would not be surprised if the patient died in the next six to 12 months.
Before addressing various types of medical interventions with patients, clinicians should  discuss the relative weight placed by the patient on prolonging life as opposed to enhancing the quality of life.

It is important that clinicians review the following with patients:

Living wills
Health care proxies
Do not (attempt) resuscitation (DNR) orders

Other life-sustaining therapies such as:
Mechanical ventilation
Feeding tubes
Antibiotics
Hemodialysis

Palliative care
Management of pain and other symptoms
Relief of psychological, social, spiritual and existential suffering
Creating opportunity to address unfinished business