The End-of-Life Conversation: Why Doctors and Patients Should Have It

It's a conversation doctors often dread: Talking with their patients about the end of life. As physicians well know, sometimes it's easier to order another round of chemotherapy or extra tests than to risk a fight with a gravely-ill patient desperate for a miracle.

Doctors are human. They don't want to disappoint. Many feel compelled to do everything in their power to save their patients. Some over-treat for fear of being sued for malpractice.

To many, death is a mark of failure. But it's also a natural part of the life cycle. When doctors avoid difficult discussions about the end of life, they do a disservice to patients, who deserve frank and honest dialogue about the end of life.

To be clear, I'm not talking about rationing care but about refocusing the conversation to reduce suffering in a patient's final days or weeks. In medical terms, we often refer to this as a discussion about comfort care.

We live in a culture that firmly resists this approach. Americans are accustomed to getting everything they want without delay. Health care is no different. Patients and their families often demand that hospitals unleash their treatment arsenals, even those that may cause pain or discomfort without measurably helping the patient.

Doctors sometimes contribute to the problem. Since many are paid on a fee-for-service basis, they unfortunately are incentivized to provide ever-more care regardless of its cost or efficacy. All of this contributes to exorbitant health care spending.

But is aggressive care always in the patient's best interest? Are we prolonging life or increasing misery?

I have struggled with these questions my entire adult life. After more than 40 years of practicing medicine, I can say that the end-of-life conversation never gets easier. But it is a conversation we must have if we intend to honor our Hippocratic Oath to do no harm.

Many hospitals and doctors are trying to tackle this challenge. One of the most promising efforts is unfolding in Southern California, where several of the region's largest health care providers are preparing to issue a joint set of guidelines to help physicians reduce suffering and promote dignity for dying patients.

The guidelines provide specific ways for doctors and other health care professionals to engage patients in advanced care planning before critical illness sets in so that medical decisions reflect individual values and avoid overly aggressive treatments that can do more harm than good.

This type of support is essential not only for new doctors but for established physicians who have practiced for decades without ever having learned how to speak with patients about death.

It's no wonder they never learned. Medical schools do not teach this subject. Instead, doctors are left to figure it out for themselves. We would never let a doctor remove an appendix or fix a broken leg without proper training.

Part of the problem is that doctors often don't know when to have the conversation. They're reluctant to broach the subject early in treatment for fear of dashing a patient's hopes. But waiting too long also has consequences. Gravely ill patients and their families are sometimes unable to make meaningful decisions when time is short.

The time to talk should be when the patient is reasonably well and not in too much discomfort. Decisions should be made after patients, family and physicians talk. Doctors, who can be paternalistic at times, need to listen because they don't always know what's best.

Doctors and nurses can help ease this process by encouraging patients to fill out advanced health care directives to specify what type of care they want at the end of life and under what circumstances they would not want to continue living.

Directives should become a standard part of the doctor-patient relationship and should be filled out by all adults, whether sick or healthy. At the very least, anyone with a chronic progressive illness such as cancer or congestive heart failure should complete one.

It's just as important for patients to control the way they die as the way they live. Physicians have a golden opportunity to do their part by helping patients and families navigate the final leg of life's journey. All they need to do is take the time to have the conversation.

Glenn D. Braunstein is vice president of clinical innovation at Cedars-Sinai Medical Center in Los Angeles.